Headaches, is the pain the whole story?

With headaches asking for a description of the nature of the ache or pain and whether it is to a part of, or the whole head, is basic. And, adding to this, is it a first event, or is there a past experience? Is there a pattern of frequency and duration? What other symptoms are associated? The history alone will usually allow classifying it as a primary or secondary.

Let us begin with a classification clarification. The therapeutic paradigm is with a primary cause you concentrate on relieving a pain in the head, and with a secondary you first seek to address another malady underlying it, and this then relieves it, or is dealt with as second priority, or it was tragic.

The history of a head injury and even a brief unconciousness and then a headache, is secondary, and needs in hospital observation. An infrequent congenital weakened artery at the base of the brain may present as a sudden onset,'thunder clap' headache, and it can be confused as like a migraine. But, such may give reprieve then suddenly extend, the concern of an impending blood vessel rupture takes priority. There are many viral and bacterial systemic infections where the head pain is a prominent component. And, ditto with a number of viral and bacterial meningidities and encephalidities. These latter conditions are tangential to this discussion, and are not enlarged on. But, for this note. A person,with the history of tension type headaches may develop an intracranial tumor, and this should gain priority of concern, but it may remain hidden, being masquaraded by the first diagnosis. When head pains change in frequency, duration or character, it is worthy of note.

The primary headaches are subdivided into: muscle contraction, vascular, traction, inflammatory and cervicogenic in types.

Do you have muscles in your scalp? Well, you already know it, but to reinforce it, look in the mirror - if you can raise and lower your eyebrows and put vertical wrinkles there, you have the muscles. And, if you've lived an average life, and have played a sport of vigorous activity after long time of inactivity then have you experienced sore muscles. Holding a muscle in continuous contraction is very unphysiological, and, suggestively, leaves the muscle a continuous anaerobic energy cycle. The acidic chemical wastes would build up in the muscle cells quite fast. Have you ever tried to hold your hand out steady for half an hour?

The second type of pain sensor occurs at the tendons at the back of the head, and the muscles too, may have soreness or tenderness. (This is not unique to the head, but the back and other areas are not under discussion.) Under this reference a prolonged posture of leaning over a desk would cause soreness to the back of the head and the neck muscles that move the head and shoulders. Though an isolated tendon can be stretched, strained, to soreness, let us co-apt that fibrocitis and myocitis play into this. These latter conditions are inflammatory in type.

The cervicogenic headache is referred pain or/and a reflex tension pain to the back neck muscles. The upper neck vertebra, by arthritis, by wear and tear, by malalignment, or by post trama (whiplash) are the source of the headache.

Let us submit that a voluntary muscle can be subconsciously stimulated to be in continuous contraction from a perceived situational threat. And, let us submit also that the same voluntary muscle can be reflexly held taut by pain receptors and that the muscle and the muscle soreness in both cases would be alike. Then, does it not follow that in the two similar 'tension' type headaches might require significantly differing approaches?

Now, I have indicated that interpreting the cause and finding the best approach to a sore head muscle can be a clinical challenge. We may add to our clinical challenge by considering the 'migraine' complex. The literature points out that it occurs less commonly than the tension type, it is the second in incidence of headaches overall. The migraines are classified as primary vascular headaches.

Intuitively one might conclude that if the head pain throbs in tune with the heart beat it is a blood vessel pain, it is vascular. But, not all throbbing headaches are migraine. This feature can occur with intracranial tumour headaches, without antecedent head trauma, without fever. Throbbing with a fever tips it into the secondary headache zone.

In medical text book the 'migraine' complex includes symptoms without a headache.

In migraines the signs and symptoms are commonly lateralized. Thus the onset of a migraine with lateralized leg or arm weakness, is, until it reverses, like a cerebrovascular accident. Fortunately, the motor symptoms are fleeting, and the combination of other symptoms and onset at a young age, allow for stalling observation without expensive tests, or of undue apprehensiveness.

It may be of interest here to learn how the name 'migraine' came to be. Here is how I understand the story. Scholars used to borrow phrases from Latin and Greek. The cranium is where the brain is stored, and, hemi means half in Greek. So, in discussing a clinical problem that incriminates one side or the other of the brain, a clinician in doing a dissertation might combine the two phrases and come up with the newly coined word 'hemicraine'. And from the French phonetics this becomes 'migraine' in English, as the 'h' in French is almost imperceptible.

In migraine we incriminate the artery at the base of the brain as the site of pain location. But, the usual symptom pattern of an altered mood and an altered alertness and, possibly, visual disturbance and other symptoms, and then the unilateral throbbing pain argues that the artery is not the initiating site of disturbance. The sequence of events is not inconsistant to a locus of brain hyperactivity affecting only defined areas of viscera innervation and pain sensing areas. Migraines are like a seizure disorder.

The pain in migraine lies within the distribution of the Vth cranial nerve, also called the trigeminal because it has three main branches. This nerve also carries sympathetic fibers so it can restrict blood flow through a vessel innervated by contracting it. The V1 branch innervates the opthalmic artery which supplies blood to the opthalmic nerve and the retina. It is conceivable that when visual aura occur it is by activity in this nerve, by both vasoconstriction or/and nerve ending hyper activity over the opthalmic artery. Other cranial nerves are involved, like the vagus, when there is abdominal pain or vomiting.

It is noteworthy that occlusion of any branch of the basilar artery, which is the artery of note in migraine, creates no neurologic loss that matches the clinical nerve malfunction in migraine. In migraine the arteries are secondarily involved, but remain healthy.

It is also noteworthy that the opthalmic artery can develop a serious inflammation, called giant cell arteritis. This condition is also called cranial, or temporal arteritis, and it occurs infrequently, and it strikes the elderly, well past the age of migraine onset.

Because I have available the notes of a mid-seventy year lady of an actual case of temporal arteritis and because of its poignancy I will present the case.

July /03 - Became conscious of blurred vision; thought it might be cataracts.

Aug01/03 - Appt. with opthalmologist; found vision good, no cataracts; was given artificial tears; blurring not helped.

- muscle pains developed, and she woke up tired and stiff in the mornings.

End Nov/03 - developed pain in the right groin, which moved to hip and back; pain slowly diminished and ended by Feb/04.

Dec03/03 - had X-ray of hip, learned of slight touch of osteoporosis and arthritis in spine

Feb19/04 - Severe headache above left eye, which moved to beside right eye in 2 weeks. Kept pain somewhat under control with pain killers for a month.

Feb24/04 - Went to an Urgent Care Center; Dr. suspects Temporal Arteritis based on a high sedimentation rate and prominent temporal arteries; concerned Dr.makes a referral.

Seen by student and two neurologists - find blurry eyes complaint and sed rate has dropped a bit, findings are inconclusive of temporal arteritis.

Mar10/04 - sed. rate up from 43 to 59, hemoglobin a bit low. Has severe muscle pain and stiffness all the way down the back, from the head to the back of her knees.

Mar15/04 - sed rate is 45.

Mar19/04 - Echocardiogram; done for separate reason, has had leaking heart valve many years, on heart meds since Feb06/04

- Dr. phones patient to enquire how she is; patient indicates she is running out of painkillers and asks to be treated; Dr. asks what she wants to be treated for? The patient explains according to the Merck Manual of Medical Information she has Temporal Arteritis with Polymyalgia Rheumatica without depression. She is put on Prednisone 30mgs./day. In 10 days the pains are gone and sed rate drops to 16. Patient rejoices.

Apr05/04 - eyes very blurry; 15-min. blindspot while in a store; next day at a store vision very blurred, sees almost nothing, becomes very naseated, later in week double vision developed.

Apr13/04 - Totally blind in right eye; next day sees her Dr. and neurologist, and both seem shocked. Medication is upped to 50 mgs./day

PS Observations:

1. Giant cell arteritis may start in the opthalmic artery and with blurred vision the only symptom. The eye, at this stage, may give the only clue to a potential danger to loss of sight disease. There are no specific medical tests for it at this stage.

2. The pain of temporal arteritis and associated conditions respond to painkillers. A high sed rate correlates and is not unique to temporal arteritis.

3. To wait for the tempoal artery to become thick and tender enough to merit biopsy and from the respective report decide to treat or not, may be like the proverbial farmer who on noting the horse was gone reflected that he should have locked the barn door.

4. The treatment for giant cell arteritis is a higher dose glucocorticoid than is used for the associated polymyalgia.

5.Treatment side effects are significant and judgment of dosage, length of treatment, and of taper off, require medical follow through.

6.The absence of a specific test, the infrequency of occurence, and the side effects of the medication make it unlikely that giant cell arteritis starting in the opthalmic artery will receive ideal treatment on time.

PPS:

Headaches, the search for a solution may draw into it's purview the services of:

a psychiatrist an internist a neurosurgeon a general practioner

a chiropractor

a pharmacist

a herbalist

a spiritual advisor

a physiotherapist

a masseuse (masseur)