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HEADACHE

Headache is a term which literally describes pain felt anywhere in the head. Headache is probably the commonest, the most ambiguous and sometimes the most difficult clinical problem in oral medicine. It has a multiplicity of causes but is produced by relatively few mechanisms. In the vast majority of cases the cause is relatively minor and reversible but in a few patients headache may be a sign of more sinister intracranial disease.

Clinical Features

Pain in the head may be due to lesions in nearby structures, such as the eye and ear, causing referred headache; it may be due to the cranial neuralgias, meningeal irritation, vascular disturbances, traction and distortion of intracranial structures, or to psychogenic causes.

Referred Headaches:
Eye diseases such as glaucoma, nasal and sinus disease, dental and ear conditions and cervical spondylosis may cause pain spreading far beyond the area of primary pain. In sinus headache, for example, the blocked sinuses cause pain above the eyebrows, between the eyes and in the cheek bones, which is worse on stooping and wakening. Another example is a cold stimulus on the soft palate which, in some people, evokes a dull, frontal headache (ice-cream headache). In muscle contraction headache, muscles of the head and neck tighten, causing a dull, aching pain that starts at the back of the neck and moves upwards towards the temples. It often occurs in people whose work forces them stay in the one position for many hours a day.

Cranial Neuralgias:
The episodic, stabbing pain of trigeminal neuralgia and the continuous, burning pain of post-herpetic neuralgia, both occurring within the distribution of the fifth cranial nerve, present well-defined and usually easily-recognised entities. Glossopharyngeal neuralgia is less common and is characterised by pain, usually of a stabbing character, felt in the pharynx and deep in the ear. The pain occurs in bouts and may be triggered by swallowing and talking. It responds to treatment similar to that given for trigeminal neuralgia. Temporomandibular neuralgia arises as a result of derangement of the temporomandibular joint secondary to an alteration of the bite caused by loss of teeth, ill-fitting dentures or excessive clenching or grinding of the teeth (bruxism). Pain which varies from a dull ache to intense stabs may radiate from the region of the affected joint to the temporal and frontal areas, the cheek, lower jaw and occasionally to the neck. In malocclusion and bruxism, a prosthetic device called an occlusal splint to prevent overclosure of the jaw from tooth wear is a simple and usually effective treatment.

Meningeal Irritation:
Headache is an almost invariable accompaniment of encephalitis and meningitis. The headache is usually generalised though it may be more intense in the back of the head, is of a continuous aching or boring character and is frequently associated with photophobia (light sensitivity) and drowsiness. The pain is increased by exertion and even by minor movements of the head; the accompanying fever and neck stiffness usually make the diagnosis obvious. Blood in the cerebrospinal fluid (CSF) due to subarachnoid haemorrhage produces headaches and neck rigidity similar to those of meningitis, but the pain in this condition is characteristically of abrupt and even explosive onset and may be accompanied by loss of consciousness.

Vascular Headaches:
These are almost always described as throbbing in character and are aggravated by head movements. They may arise from dilatation of the intracranial or extracranial arteries after overindulgence in alcohol, in fever and in the hypercapnia of respiratory failure. Severe arterial hypertension may cause headaches in the early morning. In the elderly, localised temporal headache may be due to cranial arteritis. Migraine is the commonest form of vascular headache. Blood vessels pulsate to cause a throbbing pain which may start on one side and move to both sides of the head. Often migraine sufferers can't bear light, strong smells and noise. They also feel sick and sometimes vomit. Some people have warning signs of flashing lights, tingling fingers or a feeling of heaviness in one limb before the pain begins. A migrainous variant, 'cluster' headache, presents a distinctive picture, which is unilateral, intense and brief. Many attacks occur in quick succession during a period of a few hours or a few days, and then there is often a prolonged period of freedom, hence the name 'cluster'. The pain is usually severe and burning, primarily involves the frontal region and the eye but often spreads to the face and sometimes to the neck. It occurs most commonly in young males, characteristically wakes patients from sleep and is often accompanied by flushing of the skin, a runny nose and reddening of the eyes.

Headaches Due to Traction on Intracranial Structures:
Headaches may occur in the presence of an expanding intracranial lesion such as cerebral tumour or subdural haematoma, whether or not there is a generalised rise in intracranial pressure. Traction headache due to reduced CSF pressure may occur after lumbar puncture; patients tend to develop their symptoms when standing or sitting and a recumbent posture produces rapid relief. Traction headaches, whether produced by raised or lowered intracranial pressure, are usually aggravated by bending, straining at stool and coughing. Benign intracranial hypertension is a rare condition usually occurring in obese women. It causes traction headaches un-associated with any space-occupying lesion.

Psychogenic Headache:
Rarely headache may be a feature of psychotic illness such as schizophrenia. Most commonly, however, psychogenic headaches are associated with anxiety and depression, and other manifestations of these affective disorders may be present concurrently. Most patients suffering from psychogenic headache describe it as of 'pressing' character. In the classic example of tension headache, stress and anxiety cause pain at the back of the neck or across the top of the forehead (like a band around the head or a weight on top of the head). Pain is usually not prominent on waking in the morning and in most instances tends to get worse as the day wears on. It is often described as severe, continuous and unrelieved by analgesics.

Some Common Trigger Factors of Headache
Investigation and Treatment

The extent and nature of investigations to be employed are determined by the history. In some of the more common forms of headache, self management of the problem may be sufficient:

Important

See your dentist at Contemporary Smiles or a general practitioner if your headache is: