The Headache Handbook

Diagnosis and Treatment

Gary W. Jay

• Publisher: CRC Press
• Year: 2021
• eBook ISBN: 9781000162202
• Topic: Medicine
• Subtopic: Neurology

The Headache Handbook: Diagnosis and Treatment helps both generalist and specialist clinicians, including family practitioners, chiropractors, and neurologists, to understand headache, possibly the most ubiquitous symptom in medicine. This comprehensive work covers the myriad of differences among headache patients and the need for accurate fact gathering and physical and neurological examinations. Topics include anatomy and physiology of headache; evaluation and treatment of various headache types; interventional procedures; and manual medicine consultations.

chapter one Anatomy and physiology of headache

DOI: 10.1201/9781003076032-1

The diagnosis and treatment of headache should be considered a subspecialty. Why do I say this? It takes a great deal of specialized information, as well as a lot of general information, to do it right. The purpose of this book is to give to you, the interested clinician, the specialized information you may not have had a chance to collect. The information will help you diagnostically, as well as with treatment, which will be discussed in some depth. You will learn some “tricks” of the trade, as well as some common sense things which, believe me, usually are not commonly thought of in clinical practice. We will discuss patient cases and go through the thought processes used to arrive at the correct diagnosis. We will also explore treatment, both specifically and generally, as well as the neuropharmacology of the drug treatment of headache.

Occasionally we will come to an AH HA!. This is a point of particular importance or relevance to which you may want to pay special attention. For example:

AH HA!Just because a new patient says they have migraine

headache, DO NOT take that diagnosis at face value!

Why not take what the patient says at face value? Many patients think of all headaches as being the same thing — a pain in the head. The term “migraine” means the same thing as “headache” to most of them. Diagnostic differentiation is not their responsibility; it is yours, as a clinician. Ask the patient if the diagnosis of migraine was given by a clinician. If not, start your history again. Even if the diagnosis was made by a physician, start your history again anyway. Physicians and chiropractors who do not specialize in headache can be wrong. This typically leads to unsuccessful treatment of the patient for migraine, and both patient and doctor become frustrated — the patient, because his headaches are not better, and the clinician, because he knows that the treatment he administered for migraine was correct. The patient did not get better, so there must be something “wrong” with the patient. It must be the patient’s fault! (But then, treating the incorrect diagnosis correctly does not much!) And so it goes.

When such patients finally reach someone who specializes in headache, they are angry, depressed, dismissive, and, in effect, aredaring you to help them! Remember, though, an incorrect diagnosis is not the patient’s fault. The patient’s experience, however, will make treatment more of a challenge for you now. It is intent of this book to teach you how not to make such sophomoric mistakes and how to intervene appropriately and correctly when are called to do so.

First, lets get some “words” down.

AH HA!For the remainder of this book, the terms “clinician” and “physician” are interchangeable and include both doctors of medicine and chiropractic.

We are not here to split hairs, nor fight stupid battles. Members of both professions are equally able to utilize this information. Also, to save trees, the titles of clinicians, chiropractors, and physicians are meant to mean both male and female members of the professions. No sexism allowed. Please note, too, that all non-generic medication names are trademarked.

Now that we have that all straightened out, let’s get started! This chapter will deal with the anatomy and physiology of headache. It will get pretty complex, for which we are not sorry, since that is the way the central nervous system (CNS) is built. You should be familiar with this information, as it will help you to understand (anatomically, physiologically, and, later, neuro-pharmacologically) some of the diagnostic and treatment aspects we will be talking about. There will be more anatomy and physiology later, too.

If you want to skip ahead to the chapters dealing with specific clinical entities, go ahead, but come back here later on and absorb what you can.

Because there has to be a place to start, we will begin with the cranial nerves — specifically, the functional components of the cranial nerves. I mean, we have to start somewhere! There are two types of general afferent fibers. Remember, afferent fibers carry information to the central nervous system. General somatic afferents (GSA) carry pain, temperature, touch, and proprioceptive information from sensory endings in the body wall, tendons, and joints. The general visceral afferents (GVA) carry impulses from the visceral organs within the thoracic, abdominal, and pelvic cavities. There are also special afferent fibers, including special somatic afferents (SSA) which carry sensory information from organs in the eye and ear for vision, hearing, and equilibrium. The special visceral afferents (SVA) carry olfactory and gustatory impulses.

The general efferent fibers come from motor neurons in the spinal cord, brainstem, and autonomic ganglia and innervate all musculature of the body, except the branchiomeric muscles. There are three types. The general somatic efferents (GSE) convey motor impulses to somatic skeletal muscles via fibers in the ventral roots of spinal nerves. The general visceral efferents (GVE) are autonomic axons which control smooth and cardiac muscle and regulate glandular secretion. The special visceral efferent (SVE) fibers innervate striated skeletal muscles in the jaw, the muscles of facial expression, and the muscles of the pharynx and larynx.

That being said, let’s look at various aspects of the cranial nerves. The olfactory nerve (I) consists of SVA fibers which terminate in the olfactory bulb. The optic nerve (II) consists of SSA fibers which go to the evaginated fiber tract of the diencephalon, from which they continue on through relays in the thalamus the lateral to the lobes.

The oculomotor nerve (III) contains GSA, which comes from extrinsic ocular muscles. Central processes may terminate in the trigeminal nucleus. The third cranial nerve also has general somatic efferents, fibers from the oculomotor nucleus which innervate the extrinsic muscles of the eye, except for the superior oblique and lateral rectus muscles. This cranial nerve also has preganglionic parasympathetic fibers from the accessory oculomotor nucleus (of Edinger-Westphal) and ends in the ciliary ganglion, which controls pupillary constriction and light and accommodation reflexes.

The trochlear nerve (IV) includes GSA, or proprioceptive fibers from the superior oblique muscles. It also carries fibers from the trochlear nucleus which innervate the superior oblique muscle of the contralateral eye. The trigeminal nerve (V) is as complex as it is important. It has both exteroceptive and proprioceptive afferent fibers. The former come from the skin of the face and the anterior portion of the scalp, the mucus membranes of the mouth and nasal chamber, and the dura mater of most of the cranial cavity. The proprioceptive fibers come from the muscles of mastication and other muscles innervated by the mandibular division of the Vth nerve. Fibers from both these afferent pathways end in the trigeminal nucleus. There are also efferent fibers from the motor nucleus of the Vth cranial nerve which contribute to the mandibular nerve and innervate the muscles of mastication. Pain, or nociceptive, fibers come from the face, corneas, sinuses, and mucosa of the lips, cheeks, and tongue and are carried via the Vth nerve to its sensory ganglion, known as the gasserian ganglion (also the semilunar or the trigemi-nal ganglion).

The abducen (or VIth cranial nerve) also has both afferent and efferent aspects. There are proprioceptive (afferent) fibers from the lateral rectus muscle and efferent fibers from the abducens nucleus which innervate the lateral rectus muscle. The facial nerve (VII) has general somatic afferent fibers from the geniculate ganglion which convey exteroceptive sensations such as pain and temperature from the external auditory meatus and the skin of the ear. It has peripheral (SVA) fibers which terminate in the anterior two thirds of the tongue. The preganglionic parasympathetic fibers (GVE) lead from the nervus intermedius. The postganglionic fibers terminate in the lacrimal glands and submandibular and sublingual salivary glands. Special efferent fibers come from the motor nucleus of the facial nerve and innervate the superficial muscles of the face and scalp, platysma, stapedius, stylohyoid, and the posterior belly of the muscle. muscle.

The vestibulocochlear nerve (VIII, formerly the acoustic nerve) has SSA fibers, which are peripheral processes of the cochlear part of VIII that receive stimuli from hair cells in the cochlear duct and terminate in the dorsal and ventral cochlear nuclei. The vestibular part of VIII, with fibers from the vestibular ganglion, has peripheral processes which receive stimuli from hair cells of the maculae and cristae, with the central processes ending in the four vestibular nuclei in the pons and medulla.

The glossopharyngeal nerve (IX) has GSA peripheral fibers which convey pain and temperature from the external auditory meatus and the skin of the ear, with central processes ending in the spinal tract of the Vth cranial nerve. There are GVA fibers from the petrosal ganglion which carry general sensory input from the posterior third of the tongue and pharynx. A branch innervates the carotid sinus and carotid body. SVA fibers carry gustatory sensations from the posterior third of the tongue. GVE postganglionic fibers innervate the parotid gland. SVE fibers from the nucleus ambiguus pass IX to innervate the muscle.

The vagus nerve (X) also has five different types of functional fiber types. The GSA fibers arriving at the superior ganglion convey touch, pain, and temperature from the skin of the auricle. The central processes of these cells end in the spinal nucleus of V. The GVA fibers from the inferior ganglion carry general sensations from the pharynx and larynx and from the thoracic and abdominal viscera. Central processes end in the nucleus solitarius. The SVE include fibers from the inferior ganglion which receive gustatory stimuli from the epiglottal taste buds via the internal laryngeal nerve. The GVE preganglionic parasympathetic fibers from the dorsal motor nucleus of cranial nerve X end on postganglionic neurons in the walls of the thoracic and abdominal viscera. The nucleus ambiguus sends fibers which innervate the heart. Postganglionic fibers innervate smooth muscle and cardiac muscle. SVE fibers from the nucleus ambiguus innervate the skeletal muscle in the soft palate and pharynx.

The accessory nerve (XI) has two divisions. The bulbar (cranial) portion has SVE fibers which supply the muscles of the sixth branchial arch of the larynx. The spinal portion has SVE fibers from the spinal accessory nucleus in the dorsal part of the anterior horn of C2 to C5 in the cervical cord, which exits the spinal cord through the lateral funiculus, exits the skull in association with cranial nerves IX and X, and innervates the sternocleidomastoid and trapezius muscles. The hypoglossal nerve (XII) has GSA proprioceptive fibers from the lingual musculature. It also contains GSE fibers from the hypoglossal nucleus which innervate the musculature of the tongue.

You made it through the really, really hard stuff! Congratulations! Now, take a deep breath, and let’s move on to the special senses, all four of them. This stuff will come into play later on when we deal with migraine auras and similar things.

The first special sense is theacoustic system.Acoustical stimuli pass through the middle ear, scala vestibuli, and scala tympani to Corti’s organ, where hair cells are rubbed against the tectorial membrane. Excitation of the hair cells is picked up by the cochlear nerve (VIII). Fibers enter the brainstem at the lateral pons, split, and enter the dorsal and ventral cochlear nuclei. From there, fibers proceed rostrally via the nucleus of the lateral lemniscus, the inferior colliculus on the roof of the midbrain, and the medial geniculate body. The acoustic radiation goes to Heschl’s gyrus on the cortex. Then, the dulcet sounds of Dr. Dre, Hootie and the boys, and even Wagner can be

The olfactory systemcomes complete with olfactory cells, which make up the olfactory filaments, which go through the cribiform plate and enter the olfactory bulb, the projections of which are the olfactory tract, which travels through the lateral olfactory striae to the uncus. The medial olfactory striae goes through the olfactory portion of the anterior commissure to the opposite olfactory bulb.

In the optic system, the human retina, with rods and cones, transmits impulses to the ganglion cells, whose axons form the optic nerve. From there, axons go to the optic chiasm. From the optic chiasm, optic tracts go to the lateral geniculate body, then to the posterior calcarine fissure and adjacent areas of the occipital pole. At the optic chiasm, there is a semidecussation of the optic nerves. The tracts arising on each side of the optic chiasm contain fibers from both eyes, as well as fibers from corresponding halves of each retina (right or left) to each geniculate body.

Our sense of taste begins with sensory cells from the taste buds on the tongue. These cells transmit one of four distinguished qualities: sweet, sour, salty, and bitter. Most taste buds are innervated by cranial nerve IX, the glossopharyngeal nerve. The facial nerve (VII) innervates the tip of the tongue, and the vagus nerve (X) sends branches to the epiglottis and larynx. From the taste fibers through the facial nerve, the geniculate ganglion sends peripheral fibers via the chorda tympani through the pterotympanic fissure to the lingual nerve of the mandibular branch of V or via the greater superficial petrossal nerve past the otic ganglion to the lingual nerve to the tip of the tongue. Taste fibers in the brainstem — from cranial nerves VII, IX, and X — go to the solitary nucleus, where the fibers appear to cross and ascend in connection with the trigeminal lemniscal fibers. The fibers then go to the arcuate nucleus of the thalamus and from there to the parietal cortex. And that’s how we the taste of a steak!

So much for the general, introductory, read-it-anywhere, basic information. Now we can become a little more specific (at least in terms of headache) as we describe the pain-sensitive structures of the head. One of the most fascinating aspects of the pain-sensitive structures of the head is that the brain is not one of them, in spite of being the “receiver” of nociceptive information from the entire body. Even so, a great number of pain-sensitive structures are important in our discussions. Most of them you have already read about in the cranial nerve discussion.

In no particular order, the pain-sensitive structures of the head include the skin; fascia; muscles, periostium of the skull, and upper cervical vertebrae; scalp vessels; orbital structures and the eyeball; salivary glands; teeth and gums; ears, including the external auditory canal and the tympanic membrane; mucus membranes of the paranasal sinuses; temporomandibular joints; dura mater within the skull; and the dural blood vessels including those of the falx cerebri and the dural venous sinuses. Now, the how, why, and where.

Sympathetic (efferent) nerves carried on the wall of the internal carotid artery, from the cervical plexus, supply the intracranial arteries and their branches at the base of the brain. Nociceptive (afferent) fibers from the intracranial cavity above the tentorium are carried by branches of the trigeminal nerve.

Pain is usually felt in the frontal, parietal, and occipital regions. Pain from below the tentorium is carried by branches of the glossopharyngeal and vagus nerves. It is perceived in the occipital region. Pain from sympathetic nerves supplying the internal carotid artery and its major...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Introduction
• The author
• Table Of Contents
• Dedication
• Chapter one. Anatomy and physiology of headache
• Chapter two. General thoughts on the mechanisms of headache
• Chapter three. Migraine headache
• Chapter four. Cluster headache
• Chapter five. Tension-type headache: clinical and pathophysiological aspects
• Chapter six. Evaluation and treatment of tension-type headache
• Chapter seven. Combination headache
• Chapter eight. Psychological aspects of headache
• Chapter nine. Post-traumatic headache
• Chapter ten. Orofacial pain
• Chapter eleven. Organic causes of headache
• Chapter twelve. Interdisciplinary treatment of headache
• Chapter thirteen. Nerve blocks and other interventional procedures
• Chapter fourteen. Cervicogenic headache: an introduction and manual medicine
• Afterword
• References
• Index