| Headache is a general description for a pain in the head. The condition often goes unrecognized as a potentially disabling condition leading to significant numbers of lost work days. Many headaches, however, are temporary and originate from benign conditions.
Correct diagnosis of underlying conditions causing headache can be crucial to resolving pain and discomfort. Several distinct types of headaches include those caused by tension, muscle contraction, or blood vessel abnormalities (vascular). Headaches can include severe pain in one side of the head (migraine), severe and episodic pain (cluster), or a combination of the two. When an individual experiences a headache severe enough to disrupt daily routines or work, the condition likely is a migraine.
Headache may occur without any known cause or can be a symptom of other disorders, including infections in the sinuses (sinusitis), the membranes covering the spinal cord or brain (meningitis), or the brain itself (encephalitis). Other causes may be severe, long-standing high blood pressure (hypertension), bleeding or tumor in the brain, and alcohol overuse. Hunger and an accompanying drop in blood sugar also can cause headache. Most people at some point in their lifetime have experienced muscular tension and a resulting headache. Tension headaches also may result from acute stress, chronic anxiety, or depression.
Vascular headaches (migraine is the most common) may be linked to dilation of vessels in the brain and/or scalp. Cluster headaches, a variation of migraine, occur less commonly and possibly are associated with the body's release of a chemical (histamine) during an allergic reaction or from enlargement of large neck arteries (carotid arteries).
Many disorders involving structures of the head and face can cause headaches or facial pain. Among these are acute or chronic sinusitis, middle ear infection (otitis media), inflammation within bones of the skull (mastoiditis), dental disorders, and dysfunction or misalignment of jaw bones (temporomandibular joint [TMJ] syndrome). Headaches may also result from eyestrain or can be a symptom of an eye disease such as inflammation of the colored part of the eye (iritis) or damage to the optic nerve (glaucoma). Facial pain can be caused by nerve disorders such as tic douloureux or herpes zoster.
Headaches may be a symptom of a neurological disease. The condition may also accompany central nervous system (CNS) infections (meningitis and encephalitis) and lesions that form in spaces (space-occupying lesions) where they cannot expand (cerebral hemorrhage, subdural hematoma, brain cancer, or brain abscess). Headache may also occur in system-wide (systemic) diseases affecting the CNS (severe hypertension and systemic lupus erythematosus). An extremely severe headache is the primary symptom of a ruptured blood vessel already weakened in the brain (cerebral aneurysm). A head injury (concussion or cerebral contusion) may be followed by post-traumatic headaches. Headache may also occur after a spinal tap (lumbar puncture).
Pain may be referred to the head from other areas of the body, particularly the neck, shoulders, or back. Disorders of the spine (intervertebral disc disorders) or nerve network (brachial plexus) originating in the vertebrae (thoracic outlet syndrome) may produce headaches. Headaches may also arise from disorders of muscle and fibrous tissue associated with muscles (fascia), such as neck or back strains, myofascial pain syndrome, and fibromyalgia.
Headaches may be toxic in origin (e.g., alcoholism, lead poisoning, and kidney or renal failure). Caffeine withdrawal is often overlooked as a cause of headaches. Headache may also be an adverse effect of certain medications such as nitrates used to treat chest pain (angina). In some people, glare or certain foods may trigger headaches. Fever from any cause may be accompanied by headache.Risk: Headache generally affects more women than men, although cluster headaches occur more frequently in men. Most underlying causes of headache are benign. Only about 9 in 100,000 cases of headache are due to brain or spinal system tumors (central nervous system neoplasms) (Bacon). Tension is the underlying cause for about 78% of all headaches not caused by systemic or vascular disease, or structural abnormalities (Ryan). Heavy smokers may be more likely to develop headaches. Incidence and Prevalence: In the US, about 10 million outpatient visits each year are attributed to headaches (Bacon). |
Source: Medical Disability Advisor
| History: Individuals may report associated symptoms including appetite loss (anorexia), nausea, vomiting, a runny nose, or depression. The history provides the most important diagnostic information and should include conditions at onset (sudden, chronic, age at onset), location (unilateral or bilateral, back of the neck, head, behind the eye), character of the pain (violent, throbbing, pressing or aching, boring, shock-like, worsening over time), and trigger factors (hormonal changes, menstruation [menses], changes in sleep, post-stress, certain foods, missing a meal, or weather changes). Physical exam: The exam of an individual with a benign headache disorder is normal. Physical examination of an individual with a headache secondary to an organic disorder may reveal tenderness in the temples of the head (temporal arteries), swelling of the optic nerve or disc (papilledema), fever and neck rigidity, loss of neurologic function (e.g., loss of sight, speech changes), or personality changes. The individual may need to be assessed for mental status and muscle strength. Tests: If history and physical exam suggest a typical headache history, testing is not necessary. If sinusitis is suspected as the cause of headache, sinus x-rays may confirm it. Tests recommended for sudden onset (acute), severe headaches may include imaging (CT scan, MRI) and spinal tap (lumbar puncture) in order to exclude organic abnormalities. Other tests may be recommended for individuals over 60 who have a new onset of headache or a change in the headache pattern. Tests recommended may include erythrocyte sedimentation rate or C-reactive protein, or a temporal artery biopsy to rule out giant cell arteritis (cranial arteritis). |
Source: Medical Disability Advisor
| Treatment and prognosis depend on the specific diagnosis. Appropriate treatment for any specific underlying conditions is necessary.
Preventative (prophylactic) medications that treat tension headaches may include over-the-counter pain relievers (analgesics), nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and muscle relaxants. Medications to stop a headache that has begun (abortive medications) include NSAIDs and muscle relaxants.
Prophylactic medications used for the treatment of migraine headaches may include blood pressure lowering agents (beta-blockers, calcium channel blockers), NSAIDs, antidepressants, anti-migraine agents (serotonin agonists), antihistamines, or anticonvulsants. Medications recommended to abort a migraine headache may include serotonin agonists, NSAIDs, anti-nausea medications (anti-emetics), and analgesics.
Prophylactic medications used for the treatment of cluster headaches may include calcium channel blockers, corticosteroids, serotonin agonists, and lithium (usually in rare and specific cases affecting the elderly). Abortive medications may include inhalation of 100% oxygen, serotonin agonists, a local anesthetic, analgesics, or glucocorticoids. Trigger factors such as cigarette smoke, alcohol, and specific foods should be avoided.
Treatment for all types of headache also includes nonpharmacologic treatment. Treatment may also include biofeedback, physical therapy, and guided imagery. Stress management strategies, relaxation techniques, good posture, adequate sleep, and massage may help the headache sufferer. |
Source: Medical Disability Advisor
| Prognosis can vary greatly, and depends on the identified cause. Some headaches are sporadic, relatively mild and short-term, while others can be severe and ongoing (chronic) for a lifetime. |
Source: Medical Disability Advisor
| Individuals suffering from tension headaches may benefit from outpatient physical therapy twice a week for 4 weeks. Individuals with headaches resulting from tight neck and shoulder musculature may receive massages to decrease muscle stiffness.
A heating pad may be applied as needed for 15 minutes to decrease muscle spasm. Simple stretches may also be performed throughout the day to decrease muscle tension. Individuals roll their shoulders backward and bend their neck forward, backward, sideways, and rotationally, 10 repetitions at a time, as needed.
Biofeedback has been shown to decrease muscle tension. This technique utilizes surface electrodes attached to the forehead, neck, or shoulders (whatever muscle group elicits the tension headache). A sound is emitted from the biofeedback device as it detects muscle activity, and individuals learn to relax their muscles and decrease the frequency of sound emitted. This can help retrain the muscles that are contributing to the headache. For individuals who cannot adequately manage their muscle tension, referral to a certified massage therapist may be appropriate for ongoing massage treatments.
Individuals suffering from tension and migraine headaches may require psychological counseling to help reduce stress and manage pain. Psychologists discuss possible coping mechanisms that help reduce tension headaches. Individuals learn different outlets for stress such as keeping a journal, exercising, or discussing stress in counseling sessions or with loved ones. Psychologists also may teach relaxation techniques for individuals suffering from migraine or tension headaches. These include guided imagery where individuals imagine a pleasant memory or peaceful scene. Visualization may also be used where an individual forms an image of the pain, such as a big, red ball. The ball is visualized as shrinking and turning from red to pink to white as the pain decreases.
Individuals learn progressive muscle relaxation that combines deep breathing with progressively tensing and relaxing muscle groups in sequence. Finally, individuals use meditation where their thoughts are focused on a specific idea or mental picture in order to promote relaxation. |
Source: Medical Disability Advisor
| Long-term use of pain medications can create rebound headaches and issues of dependency. Overuse of NSAIDs can result in gastrointestinal bleeding, elevated liver enzymes, kidney (renal) dysfunction, and ulcers. |
Source: Medical Disability Advisor
| Work restrictions and accommodations depend on the type of headache and underlying cause. Severe headaches may require time off from work. Headaches caused by muscle tension may need accommodation in the work space, such as ergonomically designed desks and chairs. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has the source of the headache been identified and confirmed?
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Are clinical findings associated with underlying conditions (tender temporal arteries, papilledema, fever and neck rigidity, loss of neurologic function)?
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Is underlying condition receiving appropriate treatment?
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Has individual experienced complications such as rebound headaches or drug dependency, relating to the headache?
Regarding treatment:
- Has underlying condition responded to treatment? If not, what treatment options are now available?
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Did headache symptoms respond to prophylactic or abortive therapy? Have prophylactic measures been effective in preventing headaches? Have prophylactic measures been effective in reducing intensity or frequency of headaches?
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Have trigger factors been identified? Is the headache associated with hormonal changes, menses, changes in sleep, post-stress, type of food, missing a meal, or weather changes?
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Has treatment plan included biofeedback, physical therapy, and guided imagery? Would individual benefit from including these measures in current treatment regimen?
Regarding prognosis:
- Has underlying condition responded favorably to treatment? What is current prognosis for underlying condition? How will this affect headaches?
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How disabling are headache symptoms?
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Has severity or frequency of headaches diminished with prophylactic or abortive therapy?
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Source: Medical Disability Advisor
| Bacon, Dolores J. "Headache: An Outpatient Approach to Diagnosis and Management." Columbia University. 21 Dec. 2004 <http://www.columbia.edu/~am430/headache.htm>.Ryan, R. E., and S. H. Pearlman. "Common Headache Misdiagnoses." Primary Care 31 2 (2004): 395-405. MD Consult. Elsevier, Inc. 21 Dec. 2004 <http://home.mdconsult.com>. |
Source: Medical Disability Advisor
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