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INTRODUCTION

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Of all the painful states that afflict humans, headache is undoubtedly the most frequent and rivals backache as one of the most common reasons for seeking medical help. In fact, there are so many cases of headache that dedicated headache clinics have been established in many medical centers. In addition to its frequency in general practice, many headaches are caused by medical rather than neurologic diseases and the subject is the legitimate concern of the general physician. Yet there is always the question of intracranial disease so that it is difficult to approach the subject without knowledge of neurology.

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Why so many pains are centered in the head is a question of some interest. Several explanations come to mind. For one thing, the face and scalp are more richly supplied with pain receptors than many other parts of the body, perhaps to protect the precious contents of the skull. Also, the nasal and oral passages, the eye, and the ear—all delicate and highly sensitive structures—reside here and must be protected; when affected by disease, each is capable of inducing pain in its own way. Finally, there is great concern by patients about what happens to the head perhaps more than other parts of the body because headache raises the specter of brain tumor or other cerebral disease.

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Semantically, the term headache encompasses all aches and pains located in the head, but in practice, its application is restricted to discomfort in the region of the cranial vault. Facial, lingual, and pharyngeal pains are discussed in the latter part of this chapter and separately in Chap. 44, because they pertain to the cranial nerves.

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GENERAL CONSIDERATIONS

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In the introductory chapter on pain, reference was made to the necessity, in dealing with any painful state, of determining its quality, severity, location, duration, and time course as well as the conditions that produce, exacerbate, or relieve it. In the case of headache, a detailed history following these lines will determine the diagnosis more often than will the physical examination or imaging. Nevertheless, a few aspects of the examination are worth emphasizing. For example, auscultation of the skull may rarely disclose a bruit (with large arteriovenous malformations); palpation may disclose the tender, hardened or elevated arteries of temporal arteritis; sensitive areas overlying a cranial metastasis or an inflamed paranasal sinus may be apparent; or there may be a tender occipital nerve. Examination of neck flexion may reveal meningitis; however, apart from such special instances, examination of the head itself, although necessary, seldom discloses the diagnosis.

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The quality of cephalic pain is essential to diagnosis but the sensation may be difficult for the patient to describe. When asked to compare the pain to some other sensory experience, the patient may allude to tightness, aching, pressure, burning, bursting, sharpness, or stabbing. Among the most important aspects is whether the headache is pulsatile, ...

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