Page 330 - Medicine and Surgery

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326 Chapter 7: Nervous system

Clinical features Aetiology/pathophysiology
Can be divided into prodromal symptoms, aura and The most common type of headache. The aetiology of
headache. tension headache is not known although possible factors
Prodromal symptoms may last a few days and include include stress, concentrated visual effort, previous head

mood and appetite changes. injury and analgesia abuse. It appears that the mecha-
The aura is usually visual, e.g. visual obscurations, nisms of tension headache are similar to migraine, al-

flashing lights, distortion, but may involve other though to a lesser degree.
senses, motor or speech dysfunction. Each symptom
lasts up to an hour. Clinical features
The headache begins as the aura fades. It is unilat- Somepatientshavealmostdailyheadaches,withthepain

eral in two-thirds of cases, bifrontal or generalised in constantorwaxingandwaning.Theycomplainofaband
others. It may be unilateral, then become generalised. around the head, pressure behind the eyes and a dull or
The pain may be dull or pulsating and is usually ex- throbbing headache. The presence of a long history of
acerbated by movement, coughing or sneezing. As- such headaches is very suggestive of tension headache.
sociated symptoms include photophobia, nausea and
vomiting. The headache typically lasts several hours Investigations
and may last up to several days. CT brain is not usually indicated. In acute cases in older
Migraine without aura occurs in 80% of migraine suf- patients, an ESR should be sent to exclude temporal ar-

ferers. teritis.
Management
Investigations
Reassurance, avoiding any precipitating factors and
In most cases, none are necessary. If there are neurologi-
treatment with analgesics such as paracetamol or
cal abnormalities on examination CT or MRI brain may
NSAIDs. Combination drugs which include caffeine,
be performed. codeine or ergotamine should be avoided, as they can
cause rebound headaches and substance dependency.
Chronic tension headaches may be relieved by the use
Management
of amitryptiline.
General measures include reassurance and avoidance of
precipitating factors.
Treatment of the headache involves the use of simple
Trigeminal neuralgia
analgesics especially NSAIDs which are most effec-
Definition
tive if taken early. The 5-hydroxytryptamine agonists
Intermittent excruciating pain in the distribution of one
(triptans) may be very effective. Anti-emetics may be
or more branches of the trigeminal nerve.
of value.
Prophylactic agents are used in patients with fre-

Aetiology/pathophysiology
quent headaches. They include pizotifen (a 5-hydro-
Trigeminal neuralgia is generally idiopathic. There ap-
xytryptamine antagonists), propranalol, tricyclic
pears to be demyelination of the trigeminal nerve root,
antidepressants such as amitryptiline and anticonvul-
in some cases it is hypothesised that this occurs due to
sants such as sodium valproate.
compression by a vessel, tumour or cyst. Multiple scle-
rosis is a well-described cause.
Tension headache
Clinical features
Definition Severe, brief stabbing or electric shock-like pain, usually
Recurrent headaches which are usually feel like a band unilateral, and affecting part of the face (ophthalmic,
or tight sensation around the head. maxillary or mandibular branch(es)). Severe pain may