HEADACHE A headache or cephalalgia is pain anywhere in the region of the head or neck.

It can be a symptom of a number of different conditions of the head and neck.[1] The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Nine areas of the head and neck have these painsensitive structures, which are the cranium (the periosteum of the skull), muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes. There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Treatment of a headache depends on the underlying etiology or cause, but commonly involves analgesics.

Primary headaches
The most common types of headache are the "primary headache disorders", such as tension-type headache and migraine. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head).[10]

[edit] Secondary headaches

Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches.[10] A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of "red flag" symptoms therefore means that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a new or different headache in someone over 50 years old, headache that develops within minutes (thunderclap headache), inability to move a limb or abnormalities on neurological examination, mental confusion, being woken by headache, headache that worsens with changing posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis.[10] "Thunderclap headache" may be the only symptom of subarachnoid hemorrhage, a form of stroke in which blood accumulates around the brain, often from a ruptured brain aneurysm. Headache with fever may be caused by meningitis, particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of encephalitis (inflammation of the brain, usually due to particular viruses). Headache that is worsened by straining or a change in position may be caused by increased pressure in the skull; this is often

worse in the morning and associated with vomiting. Raised intracranial pressure may be due to brain tumors, idiopathic intracranial hypertension (IIH, more common in younger overweight women) and occasionally cerebral venous sinus thrombosis. Headache together with weakness in part of the body may indicate a stroke (particularly intracranial hemorrhage or subdural hematoma) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate giant cell arteritis (GCA), in which the blood vessel wall is inflamed and obstructs blood flow. Carbon monoxide poisoning may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. Angle closure glaucoma (acute raised pressure in the eyeball) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.[10]

[edit] Pathophysiology
The brain itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the meninges.[11] Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.[12] It has been suggested that the level of endorphins in one's body may have a great impact on how people feel headaches. Thus, it is believed that people who suffer from chronic headaches or severe headaches have lower levels of endorphins compared to people who do not complain of headaches. Primary headaches are even more difficult to understand than secondary headaches. Although the pathophysiology of migraines, cluster headaches and tension headaches is still not well understood, there have been different theories over time which attempt to provide an explanation of what exactly happens within the brain when individuals suffer from headaches. One of the oldest such theories is referred to as the vascular theory which was developed in the middle of the 20th century. The vascular theory was proposed by Wolff and it described the intracranial vasoconstriction as being responsible for the aura of the migraine. The headache was believed to result from the subsequent rebound of the dilatation of the blood vessels which led to the activation of the perivascular nociceptive nerves. The developers of this theory took into consideration the changes that occur within the blood vessels outside the cranium when a migraine attack occurs and other data that was available at that time including the effect of vasodilators and vasoconstrictors on headaches. The neurovascular approach towards primary headaches is currently accepted by most specialists. According to this newer theory, migraines are triggered by a complex series of neural and vascular events. Different studies concluded that individuals who suffer from migraines but not from headache have a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex.[13] People who are more susceptible to experience migraines without

headache are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking birth control pills or are prescribed hormone replacement therapy.[14]

[edit] Diagnosis approach

The American College of Emergency Physicians have guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.[11] While, statistically, headaches are most likely to be primary (non serious and self-limiting), some specific secondary headache syndromes may demand specific treatment or may be warning signals of more serious disorders.[citation needed] Differentiating between primary and secondary headaches can be difficult. As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache.