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Referred Head Pains
When headache is caused directly by refractive errors, it usually occurs while the patient is engaged in using the eyes for reading or other fine work, not hours later. Strain from prolonged use of the eyes if refraction or accommodation is imperfect may lead to tension-type headaches. However, this is very generally known, and few patients present for diagnosis of their headaches without having had their eyes tested already. However, any of these patients may later develop migraines.
Mild glaucoma can be a cause of recurring pains in one or both eyes and forehead and will be missed unless ocular tensions are measured.
Headache resulting from disorders of the TMJ requires evaluation by very conservative oral surgeons and dentists. Abnormalities of the bite and of the joint and its meniscus can be a source of local pain around the TMJ in the cheek, mouth, ear, and temple, especially if patients also have bruxism. The pain may be felt in the face and may be misidentified as trigeminal neuralgia. Local TMJ tenderness, asymmetric opening and closing of the mouth, the presence of notable overbite, and the patient's response to the relatively cheap bite plates fitted by a dental surgeon all suggest the diagnosis. The presence of any other source of pain, such as TMJ dysfunction, is also a stimulus to an increased number of attacks of migraine in those who suffer from that condition.
Tumors of the nasopharynx that involve the eustachian tube or the hard palate may cause prolonged facial or ear pain or
The upper three cervical nerves carry pain sensation from the posterior half of the head and neck. These areas must be evaluated when considering any head-pain problems. Disturbances in one neck area may often also cause spasm and physical alterations of positioning of other neck areas, sending afferent pain impulses to the descending tract of the fifth nerve. Attention may be especially called to the neck when downward pressure on the head precipitates head pain and upward traction brings relief, when head pain extends into the neck and down the arm, or when it is associated with ipsilateral Horner's syndrome.
Cervical traction may relieve symptoms in some cases but just as often seems to aggravate them. Skilled cervical manipulation may help, as may injection of the zygapophyseal facet joints. NSAIDS are usually helpful in reducing the discomfort. Cervical collars are sometimes useful for treatment of cervical degenerative disease that is painful, but they work better if used intermittently. Theoretically, continual use of collars can weaken cervical muscles, which may aggravate the problems.
Whiplash injuries resulting in sprain and injury to multiple tissues in the neck (regardless of radiographic findings that may show no significant abnormalities) sometimes precipitate bouts of headache or accentuate previous migraine-type headaches. Recommended treatment includes short-term use of physical therapy, a soft collar, night-time tricyclic use to assist with muscle relaxation, analgesia, and explanation of the injury in terms of muscle strain and stretching of ligaments rather than rupture of joints or bones with the potential for spinal cord damage. Strong encouragement should be given to the subject to continue graded increases in activity and early return to work. The longer a person is disabled, the greater the likely legal settlement in cases involving litigation. Most people, however, do not malinger. If an opinion is given that restoration of near-normal motility will eventually be possible and that there is no evidence of damage to the spinal cord, litigation may be concluded relatively early and one more source of stress removed from the patient.
Greater occipital neuralgia is a condition of presumed stretch injury to one or both of the greater occipital nerves, sometimes caused by trauma but usually without known cause. A constant dull or boring pain is felt at the back of the head. It may radiate as far forward as the forehead (Kerr's sign). Examination reveals tenderness of the nerve (felt midway between the mastoid process and the cervical spinous processes) and possibly subjective alteration in light touch or pin sensation over the back of the head as far forward as the vertex. As in the case of other sources of cranial pain, preexisting migraine or tension-type headaches may be exacerbated by this lesion.
Local injection of the nerve with Marcaine or another local anesthetic is both a diagnostic test and good therapy; if successful, repeated injections with or without methylprednisolone may be given. For long-term relief, surgical avulsion of the nerve is sometimes advocated.
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Textbook of Primary Care Medicine, 3rd ed.
By: William Pryse-Phillips, T. Jock Murray © 2005 ELSEVIER Inc. All Rights Reserved |
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