Join Now | Sign in

Headache Health Article

Save

Marketplace

Licensed from

Page: < Back 1 2 3 4 5 6 7 8 9 10 11 12 Next >

Traction Headache

Traction headache is a relatively uncommon type of headache that results from traction on the pain-sensitive structures inside the head—the V, VII, IX, and X cranial nerves; the basal meninges; the intracranial venous sinuses; and the intracranial arteries up to their second branch off the circle of Willis. Inflammatory and mass lesions are the most common causes (Fig. 160-7). The pain arising from distortion of intracranial pain-sensitive structures is not as characteristic as one would like and is often described just as a steady, dull, bursting or pressure sensation felt deep within the head that is not as severe as migraine. Unfortunately, patients with other headaches use the same words occasionally, so this description is not diagnostic. The pain has no rhythm to it, but tends to be continuous and is seldom throbbing. It is often relieved by aspirin or cold packs applied to the skull, giving a false sense of security. It is poorly localized and may be referred to the eyes or neck. Special times of occurrence include the early morning, with some relief being obtained from the upright posture as the day goes on. Any further increase in intracranial pressure, as with stooping, coughing, or bending, makes the headache worse. A history of head and/or neck injury during recent months, especially in elderly patients, should raise suspicion of subdural hemorrhage.

The site of the headache may have some diagnostic value because most subjects with brain tumors complain of pain over or near to the region of the underlying mass. Those with posterior fossa lesions often have occipital headaches; unfortunately, associated neck muscle tension and neck stiffness or tenderness may suggest muscle contraction headache unless the other characteristics are noted. Another danger is that this headache is often not very bad in the early stages, and the patient's description may not be precise, leading to a false sense of security. Some growing tumors merely accentuate the patient's "usual" headache (e.g., of muscle contraction or migraine). Thus the diagnosis is indeed difficult and this situation points up the need for a careful neurologic examination in all patients with head pain.

The symptoms associated with traction headache depend on the rate of expansion of the mass and its site more than its actual size. Vertigo, nausea, vomiting, drowsiness, pain on ocular movement, and irritability are commonly found in association. If high pressure causes herniation of intracranial contents, then hypertension, drowsiness, bradycardia, and such localizing signs as VI or III nerve palsies may appear, as may any other focal disturbances of brain function. The causes are those of increased intracranial pressure. Idiopathic intracranial hypertension (see below), obstructive hydrocephalus, intracranial infections, cerebral edema, tumor, and hemorrhage are examples. Treatment is determined by the cause, or by temporary reduction of increased pressure using mannitol or steroids.

Idiopathic Intracranial Hypertension

When a patient (most often a young woman who is obese) presents with complaints of the onset of a new headache and has papilledema without other physical signs, the diagnosis is straightforward. Without such evidence of increased pressure, however, these patients may be labeled as suffering from a functional headache. The headache features are not specific and may resemble those of migraine, traction headache, or both. They are usually worse in the mornings and with any activity that raises intracranial pressure. Patients taking large amounts of vitamin A or hormonal therapy are also at risk. Neurologic referral is suggested in all such cases.

Low Pressure Headache

Low cerebrospinal fluid (CSF) pressure also may cause headache, especially when the patient sits or stands up. This is usually caused by a leak of CSF after LP. In the presence of a CSF leak, headache manifests when the patient stands up and goes away when he or she lies flat. A repeat study shows that the CSF pressure is very low, perhaps unmeasurable. Eventually the hole in the dural sac will heal and CSF will no longer leak. This type of headache may be avoided by using a small needle for LP with the bevel horizontal (thus splitting rather than cutting the longitudinal fibers of the dura mater) and by requiring the patient to lie flat for 2 hours after the procedure. Occasionally, true "drainage" headaches persist over days, in which case treatment requires the injection of a few milliliters of the patient's own blood into the lumbar spinal canal, "patching" the leaky dural hole. Fluid ingestion and tight abdominal binders are quite useless.

CSF leaks resulting in chronic postural headache occur also as a result of congenital defects, neoplastic invasion of the meninges, or vigorous athletic activity. In these conditions a dural tear opening a passage between the cranial and nasal cavities may have occurred. Constant dripping of clear fluid from the nose is a useful symptom; some of the fluid must be collected for evaluation of glucose content. If glucose is present, the fluid is probably CSF. When such a leak is strongly suspected, a radioimmunosorbent assay (RISA) scan is performed, with pledgets placed in the nose and sinus areas to detect radioactivity from the leaked CSF.

Patients with congenital defects in the cribriform plate and other areas of the skull where CSF can escape into the nasopharynx may have repeated bouts of meningitis. These episodes are often mild but are potentially dangerous.