head of the class

I have a headache. Simple, direct and yet those words fill an ER doc with dread. Tension, sinus, migraine, tumor, encephalitis, meningitis, vasculitis. The head is chock-a-block with things that can go from bad to dead very quickly.

Most headaches are benign. The muscles of the face, scalp and neck are prone to the stresses of our 24/7 life style. Too little sleep, too many deadlines, too much eye strain while working with computers: all can lead to tightening and spasms that cause tension headaches. Usually described as dull and aching, these cephalgias (head pains) are made better by rest and non- prescription pain medications. Reproducing or exacerbating the pain by palpation of the face or scalp are strong indicators that this benign headache is the culprit.

Sinuses are air filled cavities within the head. They function to warm and moisten the air we breath. They make the head lighter in weight. The problem arises from the fact that sinuses communicate with the nasal cavities by small holes, ostia. Infections, dry or polluted air, smoking, and allergies can all cause swelling that block the ostia. Fluid and air pressure build up and voila, a "sinus headache". Dull to sharp, worsened by bending forward, pain often is elicited by tapping over the forehead or cheeks. Decongestants, steroid nasal sprays and NSAID's are all helpful in treating sinus headaches. True bacterial sinusitis is much less common. The medical criteria include localized sinus pain, fever, tenderness, purulent drainage and even redness over the sinus for at least a week. All too often unnecessary antibiotics are prescribed for any sinus headache.

The word migraine is derived from the word hemicrania, half a head. These headaches are usually one sided, throbbing, and frequently associated with nausea, vomiting, and sensitivity to light and sound. There are several variations of migraine. Migraineurs (the French have been at the forefront of neurology for centuries) may have auras. These are sensations of smell, vision or hearing that warn the sufferer that a migraine is coming. Migraines can even mimic strokes, with abnormal sensations, visual changes or paralysis. The patient who has a known history of migraine should always be asked if this episode is worse than usual.

Cluster headaches are another variety of vascular headache. Unlike migraines, they are more common in men than women. One sided, often felt behind the eye, they are excruiatingly painful. They last seconds to hours. The "cluster" refers to the fact that pain comes and goes for hours to days, often followed by periods of weeks or months without any pain. Sweating, pupillary changes and even facial muscle weakness may accompany a cluster headache.

The elderly patient may present with a headache from inflammation of the arteries of the head. Temporal arteritis is often heralded by a dull to throbbing headache of the temple in someone older than 60 years. The ER doc must have a high degree of suspicion for this condition. If it goes untreated, it may progress to permanent vision loss.

Infections of the brain (encephalitis) or the meninges (the body tissues that cover the brain and spinal cord) can present initially with headache. Fever, neck stiffness, nausea and vomiting may help lead to the correct diagnosis. Unfortunately, early in the course of these infections it is easy to attribute these symptoms to the flu. CAT scans and lumbar puncture (LP or spinal tap) are required to make a definitive diagnosis. Delays in treatment may lead to severe disability or death.

Aneurysms are bulges that form in arteries. The brain receives a large share of the blood pumped out by the heart. The brain comsumes a great deal of the body's energy. Supplying the brain is a plumber's nightmare of arteries and veins. Berry aneurysms arise from the circle of Willis at the base of the brain. Arterial branches off this circle are the location of these timebombs. They produce no symptoms until they leak. Any headache that comes on abruptly and is described as severe, or the worst headache of the patient's life, is a subarachnoid hemorrhage(SAH) until proven otherwise. SAH is blood leaking out of an aneurysm or other weakened area of the vascular supply such as an arteriovenous malformation. A CAT scan will usually reveal the SAH. Even with a normal CAT scan, the ER doc may perform an LP as a small number of SAH's are not seen on CAT scan.

Tumors within the skull will eventually cause cephalgia. The cranium composed of the bones of skull is rigid. As a tumor grows it puts pressure on the surrounding structures and a dull but steadily worsening headache occurs. There may be some change in the intensity of the pain with changes in position.

It is ironic that the brain itself is insensitive to pain. We have seen on medical programs the brave neurosurgeon operating on the fully awake patient. Once the cranium and meninges have been anesthetised, the neurosurgeon can cut or cauterize brain tissue with the patient being awake and painfree.

From the benign to life threatening, "I have a headache" is a minefield that the ER doc must navigate. Head injuries will be "tackled" in a future blog. Take two tablets and call me in the morning.