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Diagnosis and treatment ideas should be clear
Although headache is a common clinical symptom, it is not easy to diagnose because of the wide variety
.
It may result from a primary headache disorder or it may be a clinical manifestation of multiple disorders with different causes that result in very different
treatment and prognosis.
Most headache disorders are diagnosed primarily by clinical presentation rather than as collateral tests
.
As a result, a large proportion of patients are not diagnosed accurately and promptly, resulting in unnecessary tests and ineffective treatment
.
This article summarizes the classification and differential diagnosis ideas of headache in detail, hoping to make you all gain something ~
There are four questions
in the diagnosis and treatment of headaches: Is it an emergency treatment of life-threatening headaches?
Q2: Is it a secondary headache?
Q3: Classification of characteristics of primary headache?
Q4: Painful cranial neuropathy and other facial pain and other types of headaches?
Classification of headaches
Primary headache: (1) migraine; (2) tension-type headache; (3) cluster headache and other trigeminal autonomic headaches; (4) Other primary headaches: primary knife headache, primary cough headache, primary exertion headache, primary headache related to sexual activity, sleep headache, primary thunderclap headache, persistent migraine headache, new daily persistent headache, etc
.
Secondary headache: headache due to (1) head and neck trauma; (2) headache of head and neck vascular lesions; (3) headache of non-vascular intracranial disease; (4) Headache of withdrawal from a substance or substance; (5) headache of infection; (6) headache with internal environmental disorders; (7) Head and face pain in the skull, neck, eyes, ears, nose, sinuses, teeth, mouth or other head and facial structural lesions; (8) Headache
of mental illness.
Urgent treatment of life-threatening headaches
Subarachnoid hemorrhage and other cerebrovascular accidents: sudden thunderclap headache (pain onset peaks within 1 minute), requiring head CT to confirm the diagnosis;
Carotid artery dissection or vertebral artery dissection: acute or subacute neck pain or headache with Horner syndrome and/or neurologic deficit, requiring a definitive diagnosis by head CTA;
Aseptic meningitis (Koyanagi Harada syndrome): headache with fever, strong neck, ocular symptoms, tinnitus, hearing loss, requiring lumbar puncture for definitive diagnosis;
Cavernous sinus thrombosis or arteriovenous malformations: headache with ocular or visual symptoms (eg, with periorbital pain or ophthalmoplegia), requiring a definitive diagnosis of cranial MRA + MRV;
Posterior communication aneurysm: headache with eye or visual symptoms, with dilated pupil on one side, requiring cranial MRA and extraneural consultation to confirm the diagnosis;
Glaucoma and optic neuritis: headache with eye or visual symptoms, accompanied by iridescent vision and unilateral vision loss, requiring ophthalmological consultation to confirm the diagnosis
.
Secondary headache recognition
(1) Sudden headache: it is necessary to consider the possibility of subarachnoid hemorrhage, cerebral hemorrhage, tumor stroke, brain trauma, intracranial mass lesions, especially posterior cranial fossa mass lesions, neuroimaging, lumbar puncture and other examinations can be considered
.
(2) Gradually aggravating headache: it is necessary to exclude intracranial tumors, subdural hematomas, etc.
, and neuroimaging tests can be identified
.
Patients with chronic headache with increasing frequency must also rule out pain medication overdose headache
.
(3) Headache accompanied by signs of systemic lesions (such as fever, neck rigidity, rash): attention should be paid to intracranial infection, systemic infection, connective tissue disease, vasculitis, etc.
, in addition to neuroimaging examination, corresponding blood tests and cerebrospinal fluid examinations
can be performed.
(4) Headache accompanied by papilledema, focal symptoms and signs of the nervous system (except typical visual and sensory aura), cognitive impairment: mostly secondary to intracranial mass lesions, intracranial venous sinus thrombosis, arteriovenous malformations, intracranial infection, stroke, connective tissue diseases, etc.
, neuroimaging, electroencephalogram, lumbar puncture or blood tests must be performed to confirm the diagnosis
.
(5) New headache after the age of 50: neuroimaging can be used to exclude intracranial mass lesions, if temporal arteritis is suspected, the blood sedimentation rate and C-reactive protein levels should be detected, and biopsy can be performed if necessary to confirm the diagnosis
.
(6) Headache during pregnancy or postpartum: it is necessary to pay attention to the possibility of cortical vein and sinus thrombosis and pituitary stroke, and neuroimaging examinations
such as MRV can be performed.
(7) New headache in cancer patients or AIDS patients: neuroimaging, lumbar puncture and other examinations should be performed to exclude metastases, opportunistic infections, etc
.
Examples of secondary headaches▌ Glossopharyngeal neuralgia
in the tongueopharyngeal nerve, as well as in the distribution of the ear and pharyngeal branches of the vagus nerve, characterized by a unilateral transient tingling and sudden stop.
Pain in the ear, tongue base, tonsil fossa, and/or under the mandibular angle, usually triggered by swallowing, talking or coughing, and touching the affected pharyngeal wall, tonsils, base of tongue, and mandibular angle, can cause seizures
.
May remission and recurrence
in the form of trigeminal neuralgia.
- Diagnostic criteria:
A.
Recurrent unilateral pain that appears in the distribution zone of the labharyngeal nerve1;
B.
Pain is consistent with the following four items: 1.
Each time lasts a few seconds to 2 minutes; 2.
Severe; 3.
Electric shock, tear, needle or sharp pain; 4.
Induces when swallowing, coughing, talking or yawning;
C.
Not better explained
by other diagnoses in ICHD-3.
- Treat:
1.
Drug treatment tends to be sedatives, analgesics, surface anesthetic sprays
.
Relieves pain and attacks
.
Intravenous hormones, low molecular weight dextran , oral carbamazepine, phenytoin sodium, etc
.
2.
Occlusion therapy: the glossopharyngeal nerve is adjacent to the internal carotid artery, vein, vagus nerve, accessory nerve, etc.
, and it is easy to damage peripheral nerves and blood vessels when closed, so it should be used
with caution.
3.
Intercurrent treatment: generally use the opposition method
.
4.
Surgical treatment
.
▌ Intermediate neuralgia
is a rare condition characterized by brief paroxysmal pain in the deep ear canal of the external ear, sometimes radiating to the parietal-occipital region
.
In the vast majority of cases, vascular compression may be found during surgery, sometimes thickened arachnoids, but it can also be unexplained, either a complication of herpes zoster or, rarely, multiple sclerosis or a tumor
.
Irritation of the posterior wall of the external auditory canal and/or the area around the pinna can be triggered
.
- Diagnostic criteria:
A.
Unilateral paroxysmal pain present within the distribution of the intermediate nerve1 and meeting the criteria
.
B.
Pain has all of the following characteristics: 1.
Lasts for seconds to minutes; 2.
Severe; 3.
Tearing, pinprick, or sharp pain; 4.
Stimulation of the posterior wall of the external auditory canal and/or the area around the pinna can be induced
.
C.
Not better explained
by other diagnoses in ICHD-3.
▌ Pintosensory pain
in the posterior part of the scalp, unilateral or bilateral paroxysmal tear-like or pinprick pain in the distribution of the large occipital, small occipital and/or third occipital nerves, sometimes accompanied by loss of sensation or dysesthesia in the affected area, usually accompanied by tenderness
of the affected nerve.
- Diagnostic criteria:
A.
Unilateral or bilateral pain within the distribution of the large occipital, small occipital and/or third occipital nerve and meeting criteria B-D;
B.
Pain meets at least 2 of the following 3 characteristics: 1.
Recurrent paroxysmal pain, lasting a few seconds to minutes; 2.
Severe; 3.
Tearing, pinprick-like or sharp pain;
C.
Pain is associated with the following 2 items: 1.
Benign irritation of the scalp and/or hair can cause significant sensory loss and/or tenderness; 2.
Consistent with 1 or 2 of the following: a) tenderness of the affected nerve branch; b) The place of the great occipital nerve or the C2 distribution area is the trigger point;
D.
Affected nerve meridian local anesthetic blockade can temporarily relieve pain;
E.
Not better explained
by other diagnoses in ICHD-3.
▌ Carotid artery pain, a rare syndrome is paroxysmal pain and tenderness based on the carotid artery surface pain in the neck, carotid artery pain, first described by Fay (1927), and in 1932 with electrical stimulation of the carotid artery ball induced atypical head and neck pain
。
Etiology: Hllger (1949) proposed that spasm of the carotid artery system (carotid bulb) is caused by an imbalance of
the sympathetic nervous system.
It has been suggested that the syndrome resembles cluster headache, with pathological features of carotid bulb dilation and limited tenderness in the carotid bulb; A few have mild noninfectious pharyngeal mucosal hyperemia
.
Most cases can be diagnosed based on history and physical examination, and a few need to be supplemented by cervical X-ray lateral radiograph, CT, Doppler, MRI and carotid angiography to rule out other diseases, and need to be distinguished from
Costen and Sluder syndrome.
Occasionally, the cause is arteritis (such as giant cell arteritis) or arterial dissection
.
Most patients cannot find the cause
.
In the process of diagnosis of headache, the patient's medical history should be taken as the most important diagnostic basis, first determine whether the headache is primary or secondary, the diagnosis and treatment of secondary headache patients, the most important thing is to timely identify life-threatening headaches
that need urgent treatment.
References:[1]Lv Xuexuan.
Be wary of high-risk acute headaches.
Family Medicine.
2022, (04).
[2] Liu Na,Liu Tao.
Characteristics of related diseases with headache as a clinical manifestation.
Medical Theory & Practice.
2014,27(07)
