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Of all the painful states that afflict humans, headache is undoubtedly the most frequent and rivals backache as the most common reason for seeking medical help. In fact, there are so many cases of headache that special headache clinics have been established in many medical centers. In addition to its frequency in general practice, many headaches are caused by general 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 a knowledge of neurologic medicine.


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 greater concern about what happens to the head than to other parts of the body, since the former houses the brain, and headache frequently raises the specter of brain tumor or other cerebral disease.


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 put aside as something different and are discussed separately in the latter part of this chapter and in Chap. 47, on the cranial nerves.


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. Although the examination is unlikely to be revealing, a few aspects are worth emphasis. Auscultation of the skull may disclose a bruit (with large arteriovenous malformations), and palpation may disclose the tender, hardened or elevated arteries of temporal arteritis, sensitive areas overlying a cranial metastasis, an inflamed paranasal sinus, or 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.


As to the quality of cephalic pain, the patient's description may or may not be helpful. When asked to compare the pain to some other sensory experience, the patient may allude to tightness, aching, pressure, bursting, sharpness, or stabbing. The most important information to be obtained is whether the headache is pulsatile, but one must keep in mind that patients sometimes use ...

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