Pain in the head


My ideas and thoughts on headache.


Headache is a common symptom which we all suffer from. For some they occur so frequently that it becomes part of their life.


Occasionally we pretend to have a headache and use it as a way of avoiding unpleasant situation or a person. We say, 'Not now, I have a headache...'


Most of the headaches are of benign nature. However, some may herald more serious underlying causes which may even be life threatening.


The doctor will try to exclude any serious underlying cause of headache with minimum investigations, reassure the patient and offer symptomatic treatment if no organic cause is found.


Causes of headache - Tension headache, Migrainous headache, Sinusitis, Errors of refraction, Glaucoma, High blood pressure, Cervical spondylosis, Temporal arteritis, Head injury, Raised intracranial tension (brain tumour, bleeding into brain, meningitis), Headache after lumbar puncture.


Headache with nausea, vomiting, photophobia, blurring of vision is likely to have an underlying serious condition like brain tumour. However, tension headache can go on to give rise to similar symptoms. Migraine also can cause all these.


If it is associated with fever and neck stiffness - Meningitis. Only neck stiffness, no fever - subarachnoid haemorrhage likely.


If loss of consciousness and/or paralysis - Haemorrhagic stroke or tumour.


Tension headache - severe, continuous and more a sense of pressure or tightness than actual pain. Situated at the top of the head, back of the head and neck and bilateral. History is more important as clinically there is very little to find. Patient may be anxious that he may have a brain tumour. It may be associated with depression. Depression causes loss of appetite, weight loss, loss of libido, constipation and sleep disturbance. Difficulty getting off to sleep, frequent waking, early morning waking. Headache is worse on waking, improving slowly during the course of the day.


Migraine - unilateral headache accompanied by nausea vomiting and photophobia. The patient may have eye symptoms like seeing flashing, scotoma, hemianopia prior to the headache, . Starts at teenage, more commonly in females with a family history of migraine. There may be tingling around the mouth and even paralysis of limb on one side (hemiplegic migraine). These are due to the spasm of relevant blood vessels. Basilar migraine can cause diplopia vertigo and loss of consciousness.


Temporal arteritis - tender nonpulsatile temporal artery on the side of headache. They have very high ESR. Temporal artery biopsy confirms the diagnosis. Early treatment with high dose steroid can prevent blindness.


Raised intracranial tension - most serious, least common. Brain tumour, abscess, haemorrhage. Severe headache occuring on waking with gradual improvement in the next few hours, worse on coughing sneezing straining associated with nausea and vomiting. Throbbing in character, worse on lying down, easing on sitting or standing. There may be blurred vision later.


Benign intracraneal hypertension - headache due to raised CSF pressure.


Meningitis, SAH also cause raised intracranial tension.


Sinusitis - headache worse in the morning, eases as the day progresses. Blocked and runny nose, purulent nasal discharge, fever, tenderness over the sinuses.


Investigations - FBC ESR CT head LP etc.


Treatment - symptomatic and treatment of the underlying cause. Reassurance, analgesics, sedatives, anxiolytics, antidepressants etc. are used to relieve symptoms.