LECTURE 1: The Headache
Headache - one of the most frequent painful conditions of the person, the
population meeting at 25-40 %. In structure of painful syndromes its prevalence takes
the third place after pains in a back and articulate pains.
Result of long-term scientific and clinical researches on a way of ordering
HEADACHE was creation of the International classification which consists of 13
sections and includes: a migraine; a pressure headache; claster headache; various
headache, not connected with structural damages; headache, the heads
connected with a trauma; headache, caused by vascular frustration; headache,
caused by intracranial processes of not vascular nature; headache, connected
with the use of chemical substances or their cancellation; headache, connected
with внемозговой an infection; headache, caused by metabolic infringements;
headache or the obverse pains caused by a pathology of a skull, a neck, an eye,
ears, a nose, additional bosoms, a teeth, a mouth or other structures of a skull
and the person; краниальные a neuralgia, morbidity of nervous trunks and
деафферентационные pains; not classified headache.
Secondary (symptomatic) headaches.
The headache can be the leader (and at the initial stage - unique) the complaint
at more than 45 various diseases: to a vascular pathology, a craniocereberal trauma,
tumours, infectious diseases, эндокринной pathologies etc.
To diagnostics criteria symptomatic headache
presence of clinical symptoms of the basic disease
data of laboratory and tool inspections confirming presence of the basic
disease
HEADACHE is new symptoms or appears HEADACHE other type, directly
connected with the beginning or an aggravation of the basic disease
HEADACHE disappears at successful treatment of the basic disease
Headache at a craniocereberal trauma
At diagnostics posttraumatic HEADACHE it is necessary to remember a Latin
proverb: « After that »does not mean« owing to that ». Posttraumatic HEADACHE
appears in the first 14 days after a trauma. Sharp posttraumatic pains can be caused
intracranial hematomas, traumatic субарахноидальным a hemorrhage, a brain bruise,
and also damage of superficial fabrics and inflammatory in them inflammatory and
vascular infringements. At disappearance of a painful syndrome in 8 weeks after a
trauma it is possible to speak about sharp posttraumatic HEADACHE, at большей its
duration diagnose chronic posttraumatic HEADACHE. Chronic posttraumatic pains
do not depend on weight of a trauma, months or years can remain, to have a
progressing current, in other words, get independent character. In a situation when
HEADACHE develops later than in 14 days, more often in the remote period CHMT in some months after a trauma, патогенез it, as a rule, it is not connected with
traumatic influence. Transferred ЧМТ-strong стрессорное influence, therefore very
often arises the headache of pressure having the psychogenic nature, is more rare мигренеподобные be ill. The pain has the diversified character: stupid, pressing,
drilling, is more rare-pulsing.
Thus, for diagnostics posttraumatic HEADACHE observance of time
parametres (an interval between ЧМТ and occurrence HEADACHE no more than 14
days) is necessary first of all. In other cases develops, apparently, more often meeting
primary HEADACHE (HEADACHEН). For its treatment psychotropic preparations,
psychological and social rehabilitation are used first of all.
Head бол at sharp infringements of brain blood circulation.
Frequency and character of a headache at sharp infringements of brain blood
circulation essentially differ depending on form ОНМК.
At hemorrhage HEADACHE it is observed at the overwhelming majority
sick (96 %). Patients feel intensive, bilateral HEADACHE in a kind «blow in a
head», some patients have a sensation of a spreading hot liquid in a head, strong
tightening, and then распирание. At survey HEADACHE not always comes to light
during the first hours diseases as the patient can be in a condition of psychomotor
excitation or in a coma. It is defined ригидность occipital muscles. The body
temperature
raises.
For
presence
acknowledgement
субарахноидального
hemorrhages spend lumbal a puncture, КТ, МРТ, for reason finding-out-angiografiju
at which detection arterial an aneurysm is possible, and also vascular malformation.
At ischemic stroke HEADACHE is not облигатным or a typical sign of
disease. It is marked only at third of patients, its intensity moderated, a pain have
stupid pressing character, and the discomfort in a head is frequently felt.
HEADACHE arises during the beginning of a sharp ischemia, however can and
precede an ischemic stroke; it is marked in the period of harbingers, as a rule, in a
combination to dizziness and eye dimness. If HEADACHE arises later, than in 2
weeks after a stroke патогенез it, most likely, it is not connected with sharp
infringement of brain blood circulation and develops on other mechanisms.
Neurologic research reveals очаговую organic semiology; paraclinical researches КТ or МРТ - verify presence of a heart attack of a brain.
At геморрагическом a stroke (a hemorrhage in a brain) HEADACHE the
HELL, usually in a combination to dizziness, a nausea, vomiting develops sharply,
usually in the afternoon, at height of activity of the patient, against raised.
HEADACHE can be the first symptom of disease, its expressiveness depends on
volume of an intrabrain hematoma. Carry out neurologic research for revealing
очаговой and общемозговой semiology (consciousness frustration, менингеальные
signs). For acknowledgement геморрагического character of a stroke carrying out
КТ or МРТ is necessary. Люмбальная the puncture is informative in case of blood
break in ликвороносные ways (желудочки a brain).
HEADACHE at encephalopathies.
De - A syndrome progressing multifocal or diffuse the brain defeats, shown
neurologic, neuropsychology and-or mental infringements. It is caused by chronic
vascular brain insufficiency and-or repeated episodes of sharp infringements of brain
blood circulation.
ДЭ arises in advanced age. Most great value in its development the
atherosclerosis, an arterial hypertension and their combination, though possible and
other reasons (have rheumatism, defeats of vessels in other aetiology, diseases of
blood, etc.).
The specified features allow to believe, that chronic vascular brain insufficiency
at ДЭ is not ethyological factor HEADACHE. Other type of cefalgia (see
HEADACHE at elderly) In this case takes place, is formed HEADACHE pressure or
secondary HEADACHE, connected with myofascial craniofascial
craniocervical
syndromes against an osteochondrosis of the backbone rather extended in this age
group more often; HEADACHE, connected with infringement of venous outflow,
hypoxic HEADACHE as a result of accompanying somatic diseases or a syndrome
апное in a dream.
The headache connected with an arterial hypertensia.
Establishment of reason HEADACHE at patients with ARTERIAL
HYPERTENSIA - a problem difficult. On the one hand HEADACHE the-major
clinical sign of increase the HELL, with another - extremely often arises a situation
when the patient with ARTERIAL HYPERTENSIA does not have correlation
between frequency, intensity HEADACHE and increase the HELL, and reception
гипотензивных means does not spend to its reduction. Often ARTERIAL
HYPERTENSIA flows in in general without HEADACHE. The numerous researches
spent on patients, suffering ARTERIAL HYPERTENSIA, have allowed to draw a
conclusion that chronic ARTERIAL HYPERTENSIA average or even high degree is
not reason HEADACHE. HEADACHE, caused ARTERIAL HYPERTENSIA, can
arise at sharp lifting in 24 hours after its normalisation. Such fluctuations the HELL
are marked at crysis current ARTERIAL HYPERTENSIA, a hypertensive crisis,
presence feohromocitoma, eklampsion.
To thicket at patients with ARTERIAL HYPERTENSIA HEADACHE have
the mixed character - HEADACHE, connected with sharp liftings the HELL, can be
combined with HEADACHE, caused by venous insufficiency, primary HEADACHE,
first of all with HEADACHEН.
HYPERTENSYON HEADACHE.
Increase of intracranial pressure - the important factor патогенеза
HEADACHE. It arises in the basic result of such terrible diseases, as a tumour of a
brain, inflammatory diseases of a brain (a meningitis, арохноидиты, энцефалиты, a
brain abscess) which in the absence of adequate and timely treatment death of the
patient can lead.
Гипертензионные HEADACHE have a characteristic clinical picture.
At the analysis цефалгии first of all it is necessary to pay attention of "danger
symptoms» which testify to possible progressing neurologic suffering with
development of an intracranial hypertensia and secondary character HEADACHE to
presence:
Occurrence in short enough term unusual on character (early not observed at
the given patient) HEADACHE
Прогредиентно accruing HEADACHE
Morning HEADACHE
Occurrence HEADACHE after physical pressure, strong потягивания, cough
or sexual activity
Dependence of expressiveness HEADACHE on head and body position
Increase or occurrence of new accompanying symptoms in the form of
vomiting, temperature, stable neurologic semiology
Occurrence мигреноподобных attacks for the first time after 50th years.
«Danger symptoms» demand detailed neurologic and ophthalmologic
inspection, and also нейровизуальзации (КТ, МРТ) for an exception of current
organic process.
At tumours of a brain intensity of a headache depends on rates of growth of a
tumour and its localisation rather ликворных ways.
At a meningitis (an inflammation of soft brain covers) гипертензионная the
headache can be accompanied hyperextens of heads, tonic pressure of muscles of a
neck (rigid occipital muscles), flexors by a pose of finiteness’s, increase a body
temperature, consciousness infringement.
HEADACHE, connected with reception of chemical substances or their
cancellation.
HEADACHE can be display of collateral actions of many medical products.
Usually it develops in the beginning of treatment and is more often meets at patients
disease of the cardiovascular system, receiving сосудо expanding preparations
(nitroglycerine, nitrosorbid, etc.), hypotensiv, antiaritmical means, etc.
The list of the medical products, capable to cause HEADACHE is presented in
table 1. The Causal relationship between a drug intake and development HEADACHE
is established more often retrospective, if:
Development HEADACHE on time coincides with reception of medicinal
substance
Developed collateral reaction coincides with representation about the
mechanism of action of a preparation at cancellation of medical product
HEADACHE disappears
At repeated application of preparation HEADACHE arises again
At appointment of a combination of the medical products, capable to cause
HEADACHE, their cancellation should be spent consistently.
HEADACHE can arise also at the use of alcohol and its substitutes.
Deterioration of ecological conditions, especially in large cities, pollution of
atmospheric air by exhaust gases, and also a poisoning with industrial poisons can
become reason HEADACHE.
HEADACHE at metabolic frustration
HEADACHE can arise at patients with metabolic infringements arising against
the most various somatic and эндокринных diseases. In such cases HEADACHE are
combined with signs of metabolic infringements and stop at their normalisation. If
HEADACHE last more than 7 days after successful treatment of metabolic
infringements, it is possible to believe, that they are caused by other mechanisms.
Hypoxia and hypercapnia
The most frequent reasons HEADACHE - Hypoxia , hypercapnia and their
combination. Similar metabolic infringements happen a hypoventilation consequence
at diseases of lungs - a bronchial asthma, a pneumosclerosis, an emphysema more
often, etc. is more rare гиповентилляцию the obstruction of the top respiratory ways,
reduction of excursion of a thorax at the expense of weakness of respiratory muscles
(causes at миастении, a poisoning, sedative means, etc.). Hypoksical HEADACHE
develop at mountain illness and are combined with a short wind, cardiovascular
infringements, dizziness, the general weakness, emotional infringements.
As we already spoke, primary HEADACHE (a migraine, a pressure headache,
кластерная HEADACHE), and the symptoms connected with it are the centre of a
clinical picture and unite in independent nozological the form.
Among primary HEADACHE the most widespread forms are a pressure
headache (HEADACHEН)
and a migraine. According to different authors,
HEADACHEН it is observed in 32-70 % of cases. According to the International
classification (1988) allocate incidental and chronic HEADACHEН. Each of the
listed forms can be subdivided on HEADACHEН with involving pericranial muscles,
i.e. its morbidity at manual palpation, or without that. However such division has no
essential clinical value and as believes the majority of researchers, reflects various
stages and mechanisms патогенеза HEADACHEН.
The diagnosis incidental HEADACHEН is based on following criteria:
A.Nalichie, at least, 10 episodes of the headache corresponding to criteria Б-Г.
The number of days with such headache is less 180 for a year and 15 in a month.
Proceeds from 30 minutes till 7 days.
V.Nalichie, at least, two of following characteristics of a pain: compressing or
squeezing (not pulsing) character easy or moderate intensity (the pain can reduce
efficiency of activity, but does not limit it) bilateral localisation a pain amplifies at
circulation on a ladder or similar physical activity.
G.Nalichie of two below-mentioned characteristics: absence of a nausea or
vomiting (the anorexia can be observed) absence of a combination of a photo-and a
phonophobia (one of them can be observed only).
Basic difference chronic HEADACHEН is repeatability of attacks HEADACHE
more than 180 days in a year or 15 and more days in a month. Prevalence of a
migraine is a little bit less and on the average than 16 % of patients with
HEADACHE.
For M without aura the International association had been developed following
diagnostic criteria:
1. Unilateral localisation of a headache.
2. Pulsing character of a headache.
3. The intensity of a pain reducing activity of the patient and accruing at physical
activity and walking.
4. Presence at least one of following symptoms: a nausea, vomiting, sveto - or
звукобоязнь.
5. Duration of an attack from 4 till 72 o'clock.
6. Presence not less than 5 attacks answering to listed criteria.
The aura is shown by local neurologic symptoms which accrue throughout 5-20
minutes and completely disappear within one hour. As well as at m without aura, to
an attack can precede продромальный the period. Diagnostics of M with aura is
based on criteria: d 2 attacks which are meeting the requirements of point is
accompanied, at least, by three of four following characteristics: n one (and more)
completely the reversible symptoms specifying on local cerebral корковую or
стволовую dysfunction n at least, one symptom of aura gradually develops within
more than 4 minutes, or two and more symptoms develop consistently n any symptom
of aura 60 minutes do not proceed longer; if them more than one, duration of aura
proportionally increases n a headache arises after aura during the different time period
which is not exceeding 60 minutes (it can arise also before aura or together with it).
At diagnostics HEADACHEН or M it is necessary to consider possibility of
similar clinical displays at secondary HEADACHE, that causes observance of one of
following positions: the anamnesis, somatic and neurologic inspection do not find out
presence of organic disease, other type of a headache, медикаментозно the provoked
headache or краниальной a neuralgia; the anamnesis, somatic or neurologic
inspections assume possibility of organic disease, but it is excluded by corresponding
researches; organic disease is available, but attacks of a headache of pressure are not
caused by this disease.
Despite simplicity of the resulted diagnostic criteria of the statistican shows, that
at the first reference of the patient the migraine is diagnosed in 26 % of cases, and
HEADACHEН only in 1 % of cases. Thus 38 % of sick M never consulted to the
doctor, from them of 41 % were engaged in self-treatment, 15 % did not hope, that the
doctor can really help them. In group of patients with HEADACHEН 64 % never
consulted at the doctor; 32 % were engaged in self-treatment; 13 % did not trust
doctors.
In practice doctors often should face with so-called transformed HEADACHE,
as a rule, getting a chronic current. As the most frequent transforming initial
HEADACHE factors are considered: abusing by analgetics and ergothamin (50-67
%), development of depressive displays (40-70 %), stress (22-67 %), an arterial
hypertensia (1,5-10 %), application of the preparations which have been not
connected with treatment HEADACHE (1,5-3,8 %). In many cases transforming
factors remain not identified (22 %).
For today this group GB has received the name chronic daily (or nearly so daily)
HEADACHE (ХЕHEADACHE).
ХЕHEADACHE it is not recognised as separate нозологической forms in
International classification HEADACHE and is the collective concept which has
united various types HEADACHE on the basis of the time characteristic, i.e. quantity
of episodes HEADACHE which should exceed 15 days in a month (or 180 days in a
year), and duration of each episode should exceed 4 hours. Nevertheless
ХЕHEADACHE a widespread clinical problem. Approximately 40 % of the patients
observed in specialised clinics, fall under this category HEADACHE. For a
designation of this clinical condition terms were at various times used: chronic
HEADACHE pressure, a migraine with HEADACHEН, the transformed migraine,
etc., actually reflecting pathogenetic updating of initial type HEADACHE, but not
completely corresponding to diagnostic criteria primary HEADACHE.
Classification ХЕHEADACHE is offered:
1. A chronic headache of pressure.
2. Complex HEADACHE, an including migraine and a pressure headache: the
transformed migraine; developed from a pressure headache. In turn, two last forms
can be медикаментозно induced or to develop under the influence of other factors.
3. Again arisen daily персистирующая HEADACHE.
4. A chronic hemicrany (Hemicrania continua). Besides, allocate secondary
ХЕHEADACHE: connected with a cerebral infection; the heads connected with a
trauma and changes in cervical department of a backbone; connected with vascular
frustration.
Among secondary ХЕHEADACHE influence of the transforming factors set
forth above is distinctly traced. At hypertensive illness, for example, as accompanying
chronic HEADACHEН symptoms were observed: vomiting in 18 %; dizziness in 86
%; a phonophobia in 57 % of 60 % chronic cervicogen
HEADACHE
(CHEADACHE) 18 % vomiting, 24 % sveto - or звукобоязнью, 20 % feeling of
alarm are accompanied by a nausea. There are data about a combination primary and
secondary HEADACHE, in particular, CHEADACHE in 84 % of cases are combined
with a migraine, in 42 % with HEADACHEН, in 14 % with both forms
HEADACHE.
Treatment Therapy of patients with CHEADACHE difficult enough problem.
These patients often have physical and emotional medicamentous dependence which
is accompanied by low tolerance to the psychogenic influences, shown frustration of a
dream and depression. Reception of medicines on purpose detoxication and correction
comorbid
the factors including is basic: dependence on medicines, personal
deviations (boundary and эндогенные frustration), visochno-maxillary dysfunction,
intracranial hypo-or a hypertensia. Detoxication is a difficult stage of treatment and
often demands hospitalisation. Cancellation symptoms can be observed and persist
within weeks. The most effective in these cases is the multimodal approach including
аутогенную therapy, based on the biological feedback focused on a muscular tone or
skin temperature, individual behavioural therapy, family therapy, the physical
exercises, an adequate explanation of effects of medicines and a supervision
continuity.
The general principles of treatment include: the explanation to the patient of byeffects in comparison with positive potential before is begun treatment the termination
of chronic and frequent use soothing, ergothamin and caffeine of the containing
preparations cancelling efficiency of current treatment treatment begins with small
doses, gradually increasing them depending on possibility of the patient to transfer
treatment and by-effects duration of treatment approximately from six weeks to three
months as the majority of the preparations used for treatment, have latent time of
occurrence of effective action stopping treatment, to do it gradually within several
days or weeks, to avoid effect of sudden cancellation.
In cases медикаментозно the induced occurrence of any form ХЕHEADACHE
treatment is carried out in two stages: a stage of cancellation of preparations and a
stage of selection of the therapy adequate to diagnosed form HEADACHE. Upon
termination of the period detoxication (if it is required) usual preventive therapy is
spent. Preventive treatment HEADACHEН should reduce frequency and-or weight of
attacks HEADACHE. It is spent, if: HEADACHE more often, than 2 times week, and
their duration more than 3-4 hours; HEADACHE can potentially lead to
medicamentous overdose or cause significant invalidity. Treatment HEADACHE
begins with energizers or any of preparations of specific treatment of attacks of M.
Amytryptilin is a choice preparation, begin treatment about 12,5-25 mg for the
night, gradually raising a dose on 12,5-25 mg each 3-6 days to 50-100 mg/day.
Therapeutic action begins from 2-3 weeks. It is necessary to remember presence of
by-effects, in particular, from антихолинергического actions of a preparation and
contra-indications to its application.
Main objective preventive, i.e. межприступного treatments is decrease in
frequency and weight of the attacks, providing the maximum restriction thus displays
of by-effects of applied medicines. To the preparations used with that end in view,
concern:
b-blokatory
(propranolol),
антиконвульсанты
(carbamazepine,
вальпроаты), energizers, not steroid anti-inflammatory preparations (Нурофен Plus),
verapamil.
Treatment of attacks of a migraine can be divided into nonspecific and specific
therapy. Similar division means possibility of use of some the preparations, capable to
suspend development of an attack of a migraine (specific treatment) without direct
аналгезирующего actions whereas other group of preparations (nonspecific
treatment) has the basic action decrease in intensity of actually painful syndrome.
Such approach to attack therapy is to a certain extent any, but at the same time
underlines possibility of pathogenetic treatment to what it is represented for today.
Preparations of nonspecific action concern simple both combined анальгетики and
not steroid противовоспатительные means. Necessary addition of treatment often is
application метоклопрамида.
Specific preparations are: derivatives эрготамина (0,1 % a solution
гидротартрата эрготамина till 15-20 a thaw or 1-2 mg in tablets, or
дигидроэрготамин in shape назального an aerosol); arterial hypertensiaонисты
1B/D-receptors серотонина. The estimation of efficiency of spent therapy should be
focused not only on intensity of a painful syndrome, but also on degree of
expressiveness and duration послеприступного conditions дезадаптации. In most
cases psychotherapeutic methods of treatment can be necessary addition.
The summary on lecture on a theme "Headache".
The lecture material is devoted a syndrome of a headache and intended for
students бакалавриато a 6-course.
In the given lecture the description of concept of a headache, mechanisms of
development of headaches (the vascular mechanism, change of physical and chemical
properties, гидроцефальный the mechanism, a brain hypostasis), the classification of
headaches including primary and secondary headaches is given. The characteristic of
a sharp and chronic headache is resulted.
Principles and criteria of diagnostics, development mechanisms, differential
diagnostics of primary headaches, such as a migraine, a pressure headache,
кластерная and a periodic headache are considered. Classification and migraine
clinic, principles of its treatment, including specific and symptomatic therapy is in
detail resulted.