idiopathic stabbing headache

Typically, benign HAs have a recurrent or chronic history with which the patient is familiar. The tension HA sufferer, for example, develops bandlike pressure around the head at the end of a difficult or stressful day. The onset of the HA is gradual and progressively worsens but is usually not severe or intense.

The migraine HA sufferer also typically has a history of recurrent HA, often dating back to childhood. Migraine HA is often of rapid onset, unilateral, throbbing, or beating in character. It may be preceded by scotoma and be associated with nausea, vomiting, or even transient neurological deficits, such as hemibody weakness. The HA may be triggered by eating chocolate, monosodium glutamate, or some cheeses, drinking alcohol, or taking certain medications, such as the hormone estrogen. By contrast, an HA that is life-threatening may have some of the following hallmarks: (1) first, or the worst, HA a patient has ever suffered (i.e., subarachnoid hemorrhage should be suspected); (2) first occurrence in a patient with a history of cancer (metastatic tumor); (3) accompanying fever, stiff neck, or photophobia (meningitis, intracranial hemorrhage); (4) associated loss of consciousness or severely altered mental status (intracerebral hemorrhage, brain embolism, encephalitis, meningitis); (5) associated neurological deficits that do not quickly resolve (intracerebral hemorrhage, brain embolism, brain abscesses); (6) occurrence in a patient with recent head trauma (hemorrhage, carotid artery dissection) or a history of recent foreign travel (neurocysticercosis; falciparum malaria); and (7) occurrence in a patient with acquired immunodeficiency syndrome (cryptococcal meningitis, Toxoplasma gondii, central nervous system lymphoma).

Only a few examples are given here. Almost any disturbance of body function may cause HA, including sunstroke, motion sickness, insomnia, altitude sickness, spinal puncture, alcohol withdrawal, prolonged fasting, exposure to loud noise, menstruation, psychological stressors, or new medications (e.g., nitrates).

Treatment

Mild HA often responds to rest, massage, acetaminophen, or listening to relaxing music. Moderate HA typically requires nonsteroidal anti-inflammatory drug (NSAID) therapy. Caffeine helps ameliorate many mild to moderate HAs. Antiemetics (e.g., prochlorperazine, metoclopramide) help relieve moderate to severe HAs, esp. those accompanied by nausea; ergotamines and the triptan drugs are particularly suited to treating migraines. Cluster HAs often resolve after treatment with corticosteroids or high-flow oxygen. The HA of temporal arteritis also responds to high-dose steroids, but these agents must be continued for months or years until the syndrome remits. Narcotic analgesics relieve HA pain, but habitual use may diminish their effectiveness or result in dependence.

Patient care

A description of the headache is obtained and documented, including the character, severity, location, radiation, prodromes, or associated symptoms, as well as any palliative measures that have brought relief. Temporal factors and any relationship of recurring headaches to other activities are also documented. The patient is taught to avoid precipitating or exacerbating factors. Noninvasive comfort measures (lying down in a quiet, darkened room with an ice pack on the forehead or cool compresses on the eyes) and prescribed drug therapy are instituted, and the patient is taught about these and evaluated for desired responses and any adverse reactions. If nausea and vomiting precede or accompany HA, the patient is taught to use antiemetics, and to drink fluids for rehydration once the medication has taken effect.

Treatment

Medications that alleviate cluster headaches include corticosteroids, ergotamines, gabapentin, lithium, melatonin, NSAIDs, sumatriptan and other “-triptan” drugs, and high-flow oxygen. Surgery is sometimes used to cut affected nerves.

Etiology

It is caused by the leakage of spinal fluid through a hole that fails to close when the spinal needle is removed from the dura mater. It is less likely to occur when pencil-point needles are used for lumbar puncture and when the spinal needle has a small diameter (e.g., 25 gauge).

Treatment

Bedrest in a completely flat and prone position (without a pillow), forced oral and intravenous fluids, and administration of cortical steroids are useful in treating the headache. If the headache persists in spite of therapy, it may be possible to stop the leakage of spinal fluid by injecting 10 ml of the patient's blood in the epidural space at the site of the lumbar puncture. The blood may “patch” the hole in the dura.