Pathophysiology of Headache
Migraine
Migraine is a chronic neurological disease manifested by episodes of severe headache, which significantly impacts patients’ functional activity. The initiation of a migraine attack is due to the interaction of endogenous and exogenous triggers (Wootton et al., 2021). Migraine is caused by the neurovascular mechanism, including the release of neuropeptides triggering inflammation of cranial vessels and dura mater. A separate place is occupied by the activation of meningeal nociceptors that increase parasympathetic tone.
Cluster Headache
A cluster headache is a pronounced onset of sharp pain localized in the projection of the brain to the walls of the cranium. It occurs in response to impaired enzymatic systems that inhibit hypothalamic function and mediate increased irritability (Wootton et al., 2021). Low levels of serotonin and histamine lead to vasodilation, which causes the blood flow rate in brain vessels to decrease. Cluster pain occurs in response to an inability to control brain saturation with active substances.
Tension Headache
Tension headache is localized in the forehead, presenting as a pressing and stiffening sensation. It occurs in response to activation of the CNS, which can be caused by disturbances in the secretion of neurotransmitters. Excessive pressure in cranial areas at the sites of skeletal muscle attachment leads to the development of pain (Wootton et al., 2021). With the suppression of hypothalamic function, the autonomic tone of vessels and muscles increases, causing constant spasms and provoking an intensification of pain.
Sinus Pain
Sinus pain occurs primarily in response to inflammation and swelling of the sinus mucosa. The pain results from the constant pressure of the swelling on the cerebral vessels and the disturbance of the brain’s supply. The developing negative pressure in the sinuses and the decreased partial pressure of oxygen lead to a reduction in the nasal passages and contribute to the disturbance of blood flow. Inflammatory factors gradually penetrate the trigeminal nerve and increase susceptibility to painful stimuli, provoking neurogenic inflammation.
Diagnosis and Recommendations
In the case under study, the patient most likely has a migraine. The following signs indicate it: unilateral pronounced pulsating pain (the patient described as 8/10), lasting several hours, accompanied by nausea, and increased sensitivity to light and sound (the patient hides in a dark room). The attacks last for a long time, and the first signs are observed in childhood. The presence of endometriosis is a trigger for the development of migraine. Although the patient denies the aura, it probably lasts for several minutes, and the patient does not recognize it (Wootton et al., 2021). VanderPluym et al. (2021) report that triptans, such as naratriptan or rizatriptan, are highly effective in treatment. Triptans have a more significant positive effect and less severe adverse events than other medications. VanderPluym et al. (2021) point to the effectiveness of using electrical neuromodulation and external trigeminal nerve stimulation. It is recommended that the patient determine the degree of association between endometriosis and migraine with a gynecological examination and MRI and then change from NSAIDs (naproxen) to triptans and select a non-pharmacological intervention.
Red Flags
- sudden onset – indicates an acute inflammatory process, intracranial vascular disorders;
- new neoplasms in history – the risk of intracranial metastases (Wootton et al., 2021);
- fever – the presence of inflammatory disease (meningitis, encephalitis, pneumonia), brain abscesses;
- neurologic deficits – indicates cranial hemorrhage, ischemia, and risk of stroke; the nature of pain does not indicate the severity of the deficit.
Reference
VanderPluym, J. H., Halker Singh, R. B., Urtecho, M., Morrow, A. S., Nayfeh, T., Torres Roldan, V. D., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2021). Acute treatments for episodic migraine in adults: A systematic review and meta-analysis. JAMA, 325(23), 2357–2369. Web.
Wootton, R. J., Wippold II, F. J., & Whealy, M. A. (2021). Evaluation of Headache in Adults. UpToDate. www.uptodate.com