Headaches are a common cause of suffering, but all headaches are not created equal. The main challenge to affording relief from various forms of "cephalgia." or "head pain." is categorizing a headache by type, and then proceeding with the therapy most likely to help.
The International Headache Society’s landmark work on headache classification has allowed important advances in headache study, but is somewhat awkward to use in clinical practice. One practical approach is to first distinguish "urgent" headaches (those that may be life-threatening) from others that may be less urgent, if no less distressing. Identifying "special" headaches (those that may only benefit from specific therapy) is the next step. Finally, if neither of these classifications fit, treatment of tension or migraine headache (the most common) is in order.
Urgent Headaches
Urgent headaches may be immediately life-threatening, and should be treated promptly.
Subarachnoid hemorrhage ("aneurysm")
Patients typically describe a headache related to a leaking aneurysm as a sudden, "thunderclap" headache, often the "worst headache of my life" (an "aneurysm" is a swelling of a blood vessel in the brain). After this sudden onset, the pain may persist at a high or low intensity for days. Abnormal neurological symptoms may occur, including brief loss of consciousness at the onset of the headache, a stiff neck, or eye movement abnormalities.
Such a headache mandates prompt evaluation by a physician, since a missed aneurysmal leak can result in a catastrophic stroke or death. Evaluation typically takes place in an emergency department, and includes a brain computed tomography (CT) scan. A spinal tap (looking for leaked red blood cells) may be necessary to completely rule out the diagnosis. An MRI may be useful, but typically requires neurology or neurosurgery consultation.
The definitive treatment for subarachnoid bleeding is surgery, although calcium channel blocking drugs (tioclodipine) may limit damage.
Temporal (giant cell) arteritis
Patients with temporal arteritis (TA, an inflammatory process involving the walls of medium-sized arteries) are usually over age 50. Its symptoms are newly experienced localized headache, scalp tenderness and diminished pulse over the temple area , fevers, and aches. An unusual symptom highly suggestive of TA is "jaw claudication." or cramping of the jaws while chewing.
Blindness (due to involvement of the ophthalmic artery) is a frequent complication, and may be prevented with prompt therapy. Blood tests reveal intense inflammation (with a high "ESR" test), and definitive diagnosis is made by finding inflammation on a biopsy specimen taken from the temporal artery.
