Tuesday, Feb 10 2009
Tenderness over the aching side of the head and of the nasal and paranasal sinuses, the teeth, and the ear may be conspicuous during migraine headache and for some hours thereafter. Muscles may become tender to palpation with both migraine and tension-type headaches. Thus, brushing and combing the hair may be a painful experience during or after a migraine headache. Myositis and myalgia may be accompanied by tender areas in the muscles of the head and neck. Percussion of the head may cause pain over or near an underlying brain tumor or subdural Hematoma.
Periostitis secondary to mastoiditis or frontal, ethmoid, or sphenoid sinus disease produces moderate to severe pain associated with focal tenderness. If the pain is sufficiently severe and continuous, it may become generalized. The tenderness, or hyperalgesia, associated with mastoid disease with periostitis is far greater than that associated with posterior fossa brain tumor.
Tenderness at the site of a Head injury is often associated with a scar and may persist for years. Tender muscles or nodules often occur in parts of the head remote from the site of injury.
Pressure upon the temporal, frontal, supra-orbital, postauricular, occipital, and common carotid arteries often reduces the intensity of migraine headache and headache associated with arterial hypertension. Supporting the head makes any patient with headache feel more comfortable. The pain of tension-type headache may be intensified by firm manipulation of tender muscles or regions of tenderness; however, gentle massage and simple measures of physical therapy, including heat application, frequently will relieve this form of headache.
Ptosis of the eyelid may accompany the headache of brain tumor or a cerebral Aneurysm of the circle of Willis, especially if there is a fixed and dilated pupil. Ptosis also occurs with ophthalmoplegic migraine, a symptom complex involving paresis of the muscles supplied by the third cranial nerve and occasionally those supplied by the fourth and sixth cranial nerves. It usually has its onset late in the headache attack, persists for days or weeks, and may be due to edema near or about the affected cranial nerves.
Homer’s syndrome occurs with cluster headache. Photophobia, associated with any frontal or vertex headache, is commonly seen in patients with meningitis, migraine, nasal and paranasal disease, eye disease, brain tumor, and tension-type headache. Scleral and conjunctival injection may accompany the photophobia. If the intensity of the pain is very great, lacrimation and sweating of the homolateral forehead and side of the face may also occur.
When headache is associated with papilledema, it is in most instances a result of increased intracranial pressure due to an expanding intracranial mass. However, in patients with brain tumor, headache often occurs without papilledema and papilledema without headache. In the advanced phase of hypertensive encephalopathy, headache and papilledema occur. A subarachnoid hemorrhage from a ruptured Aneurysm may cause intense headache without papilledema, but it is occasionally associated with a retinal hemorrhage. Meningitis does not affect the eye grounds except possibly to induce slight suffusion, unless there is increased intracranial pressure (and papilledema). There may be unilateral arterial and venous dilation in eye grounds during a migraine headache.
History After the Initial Visit
On occasion, a diagnosis may not be established on the first visit, or the initial assessment may be incorrect. It is useful to ask the patient to keep a headache diary for both diagnostic and treatment purposes. The frequency, severity, and duration of the headaches are logged, as are the medications and the possible headache triggers. On subsequent visits, reviewing the diary may uncover previously unrecognized patterns that can provide clues to diagnosis. The headache triggers that are identified may suggest behavioral interventions.
Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.
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