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OTHER HEADACHES

| Headache | The Diagnosis of Headache | Migraine | Tension Headache Syndrome | Cluster Headache | Other Migraines | Other Headaches |
| Treatment of Headache |

Post-traumatic headaches

Headache may follow head injury. The mechanism is unclear. They may appear even weeks to months after the injury. Individuals who are already headache sufferers may well get much worse. 
(See "Head Injury")

Chronic paroxysmal hemicrania (Sjastaad'syndrome) 

- rare, usually women
- shortlived attacks
- similar to cluster headache
- autonomic symptoms
- in most people attacks are chronic
- indomethacin (non steroidal anti-inflammatory drug) usually
very effective at 50 mg. every eight hours.

Cough and bend headache

Coughing and bending may produce severe bilateral headache which is short-lived. This can complicate structural disease sitting within the back part of the skull (posterior fossa). In he majority of patients, the symptom is quite benign, self-limiting and does respond to simple treatment.

Coital migraine 

- typically appears with orgasm but also at other times
- usually severe occipital pain of acute onset
- first attack often indistinguishable from that of subarachnoid
haemorrhage
- responds to various treatments
- more common in men

Cranial arteritis (also temporal arteritis), giant cell arteritis

- This is an inflammation of blood vessels of medium to large size. Loss of vision is a disastrous complication if not treated. Rightly leads to anxiety over a diagnosis when headache presents over the age of fifty. 
- More common in sixties and seventies. 
- More common in women who are Caucasian

Typical symptoms

a) Localised headache
b) General malaise
c) Proximal muscle stiffness and pain
d) Pain on chewing
e) Night sweats
f) Tender scalp

Management

Most important is that doctor thinks of diagnosis. On full blood test if the so-called
erythrocyte sedimentation rate (ESR) is elevated (greater than 50). Very rarely this
test can be normal. C-reactive protein also elevated as may be a serum alkaline
phosphatase. Diagnosis confirmed by biopsy of temporal artery but this may also 
be normal.

Steroids must be started immediately. I prefer high dose regime 60 mg. daily. The
dose should be reduced quite rapidly but treatment will be needed for one to two 
months with close monitoring.

Trigeminal neuralgia

Trigeminal neuralgia has a typical history. If the history does not fit within a narrow range of symptoms, then the diagnosis is probably something else. 

Condition characterised by - shortlived
- intense electric shock like pains
- recurring frequently
- usually triggered 
- always on one side of the face
- women more than men
- average age of onset at fifty

The trigeminal nerve

The trigeminal nerve arises from the back part of the brain or brain stem. The nerve splits into three. It is usually the middle and lower segments of the face that are affected. The nerves supply sensation to the face and the muscles of chewing. 

Management

Examination rarely reveals anything abnormal except for absence of shaving in men (to avoid touching the face) and similar for make-up in women. In acute attacks, there may be dehydration from inability to eat and drink.

Investigation

Investigation rarely reveals an abnormality. MRI scanning may show abnormal blood vessels compressing the nerve

Fortunately for most patients, condition spontaneously remits but then will relapse. 
Carbamazepine is the drug of choice particularly in the slow release form. Other medication may be effective such as gabapentin but needs specialist management.

A number of invasive treatments carried out by super-specialists include injecting the nerve, radiofrequency oblation of part of the nerve or an operation on the back part of the skull removing the blood vessels that cross the nerve.

Atypical facial pain syndrome

A diagnosis that is difficult to comprehend. Previously thought psychologically mediated but most neurologists doubt that this is the case. More common in women. Pain can be unilateral or bilateral or across the nasal bridge. Many texts still talk about depression and anxiety. This is not necessarily the case but the condition does respond to tricyclic antidepressant drugs usually in lower doses than the treatment of depression.

Temporo-mandibular joint dysfunction (TMJ)

The pain is on either side of the face usually within the ear or temporal region. Pain may be made worse by chewing. Joint abnormalities not necessarily present on x-ray or imaging. Commonly seen after extensive dental work and this recovers spontaneously. Frequently accompanies jaw or bite mal-occlusion. Good dentistry assists. May be history of tooth grinding or jaw clenching in sleep. More frequent in stressed or anxious individuals. Dental, physical and drug therapies often benefit greatly together with an exercise programme for the jaw.

Post-herpetic neuralgia

Usually the first branch of the trigeminal nerve. Pain accompanies shingles infection but this condition follows shingles infection (herpes zoster is the virus). More common in older people. Condition may be resistant to treatment but tricyclic antidepressant drugs with gabapentin may benefit. Surgical management including injections to the nerves of various agents may be needed.

Cervicogenic pain

Head and neck pain may arise from muscle spasm with or without wear and tear change in the neck called cervical spondylosis. Once diagnosed, the main treatment is physical with good physiotherapy. A TENS machine which is an electrical stimulator device is helpful. Similar analgesia and anti-inflammatory drugs do help acute episodes of pain.