Headache and facial pains

Abstract

Headache is the most common presenting symptom in a neurological clinic. Although seldom life-threatening, it is a major cause of suffering, and loss of productivity at work due to headache is extremely costly.

Patients seeking advice about one particular headache often have a febrile illness such as influenza or sinusitis. Nevertheless, subarachnoid haemorrhage and meningitis must be considered in every patient.

Clinical assessment of a headache patient is almost wholly dependent on an adequate history. Specific structural causes such as temporal arteritis, cerebrovascular disease, sinusitis, trigeminal neuralgia, typical facial pain, subarachnoid haemorrhage and meningitis need to be considered first. Cervical spondylosis is the commonest cause of new headache in older people. Headache as a presenting symptom of disorders causing raised intracranial pressure is unusual, as most such patients have epilepsy or physical abnormalities reflecting the site of the lesion within the brain, but patients with a short history of headache should be investigated, even in the absence of physical signs. A minority of patients have cluster headache, which all competent physicians should be able to recognise.

Tension-type headache is extremely common, though seldom as incapacitating as migraine. Physicians should ensure that the patients are not abusing opioid or other analgesics, or taking oestrogenic hormones Most of these patients respond to tricyclic antidepressants and anti-inflammatory drugs. Migraine is the commonest cause of disabling recurrent headache; in population surveys only a minority of patients have headaches preceded by a visual, sensory or other aura disturbance. Triptan analgesics should be considered for all patients unresponsive to less expensive remedies. If the attacks occur twice or more monthly, patients should be considered for prophylactic treatment, with, for example, beta blockers, pizotifen, valproate or methysergide.

With careful diagnosis and appropriate treatment, most patients with disabling headaches can be helped a great deal.