Introduction
The patient has severe headaches, nausea, and sensitivity to light and sound. Migraine is mainly found in the fairer sex, and two-thirds of cases are manifestations of menstrual migraine. Regardless of age, both women and men can have migraine cluster headaches due to physical and emotional overload, due to dietary disturbances or intrusive sharp smells, after drinking alcohol, due to weather addiction, or due to loud noise.
Pathophysiology
Migraine
Migraine is a frequent long-term neurological disorder. The pathophysiology of headache and other migraine symptoms comprises several neurogenic, vascular, autonomic, and other processes operating at various central and peripheral nervous system levels. Migraine pathogenesis is a complicated system requiring thorough investigation (Jasvinder Chawla, 2021). Many neuropeptides and neurotransmitters involved in this process are known, but the place of pain origin – central or peripheral structures – is still a subject of scientific debate.
At different stages of migraine pain, there are changes in multiple cortical and subcortical structures. Some researchers believe that the accompanying symptoms of autonomic nervous system dysfunction (nausea, vasoconstriction or vasodilation, sweating) are the links to migraine pathogenesis.
Trigeminal Autonomic Cephalgia
Trigeminal autonomic cephalgia is a very severe headache. Trigeminal parasympathetic reflex activation and ipsilateral hypothalamic activation are significant factors in the development of this disease (International Headache Society, 2023). The discovery of the central role of the hypothalamus in the pathogenesis of the disease allowed the use of this part of the brain as a therapeutic target. Following the positive results of hypothalamic stimulation, other peripheral neuromodulation targets were tested in treating refractory cluster headaches and other TVCs.
Tension Headache
The origin of tension headache involves both peripheral and central nociceptive mechanisms. The emotional factor is one of the most critical factors in the origin of pain. The episodic tension headaches are caused by transient emotional experiences, such as conflict at work, quarrels with relatives, anxiety about a child, unsuccessfully performing responsible tasks, and any other troubles that arise suddenly.
The second cause of pain in tension headaches is a factor of muscular tension, which leads to the formation of muscular-tonic syndrome – painful tension of the muscles that wrap around the head and neck. Such “muscle provocateurs” can be positional tension.
Sinus headache
Sinus headache is a type of headache that occurs when there is an inflammatory process in the sinuses, polyps, or allergic swelling of the sinuses. In an upper respiratory tract infection, swollen mucous membrane blocks the sinus accessory; after that, the oxygen inside the sinus is sucked into the blood vessels of the mucosa lining the sinus. This process results in negative pressure in the sinus, which can cause pain (Lopez, 2022). Under negative pressure, a transudate enters the sinus from the mucosa, which eventually fills the sinus; the transudate serves as a favorable environment for bacteria, which enter the sinus through the access wound or the spreading cellulitis or thrombophlebitis in the mucosa’s plate.
Diagnosis and Treatment
Migraine Without Aura
The probable diagnosis in this patient is migraine without aura. Migraine sufferers often describe trigger factors that increase the likelihood of developing a migraine attack. Each patient has a different migraine; some patients can control their symptoms independently, while others require treatment (Jasvinder Chawla, 2021). A migraine without aura is a moderate to severe throbbing headache, mostly unilateral (usually in the temporal-frontal area), lasting from a few hours to three days (Jasvinder Chawla, 2021). During a migraine attack, the patient may experience nausea and increased sensitivity to light and sound.
The diagnosis of migraine is based on a history of headaches, including their severity, frequency, “pulsation” and unilateral nature, identification of migraine attack triggers, and physical symptoms (Tejas Raval, 2022). Lifestyle adjustments, such as regular meals and sleep, can help avoid triggers and reduce the frequency of migraine attacks (Medscape, 2022). Medications are taken during an attack to reduce its intensity and long-term to reduce the likelihood of developing an attack.
Endometriosis
Another possible cause of pain could be endometriosis, a common diagnosis in gynecology, in which tissues similar in structure, properties, and structure to the endometrium proliferate outside the uterus. Taking hormonal drugs is the basis of drug therapy. Depending on the stage of the disease, monophasic contraceptives may be prescribed, which block entirely cyclic processes, preventing the growth and subsequent rejection of the endometrium and, consequently, eliminating the consequences and further development of the pathology. Taking these drugs often leads to depression, insomnia, headaches, spikes in blood pressure, and decreased libido.
Red Flags
There are red flags of headache or signs of severe pathology that should be taken seriously and go to a medical facility as soon as possible. The first is an acute, severe headache. The second red flag is a headache, which appeared for the first time. The third is a pronounced and continuously increasing headache. Fourth is a headache that worsens in a supine position. For example, the headache that worsens when lying down may be a manifestation of intracranial pressure or due to a brain tumor. A high fever accompanied by a headache may be a sign of meningitis. Examination, including MRI and, in some cases, a lumbar puncture, is often necessary if red flags are present. The most common diagnostic errors include:
- Failure to consider the fact that migraine can cause bilateral pain, which is not always described as pulsatile.
- Misdiagnosing migraine as a sinus headache or excessive eye strain occurs because autonomous and visual migraine symptoms are absent.
- The assumption is that any episode of headache in a patient with verified migraine represents a migraine attack.
- Migraine with aura may be mistaken for a transient ischemic attack, mainly if the aura occurs without headache, in older people;
- Diagnosing a sudden headache as a migraine because it goes away after taking triptan.
References
Managing migraine in primary care: 5 things to know. Medscape. (2022). Web.
Jasvinder Chawla, M. D. (2021). Migraine headache. Practice Essentials, Background, Pathophysiology. Web.
Lopez, M. D. (2022). Pediatric headache. Practice Essentials, Background, Etiology. Web.
Tejas Raval, M. D. (2022). Facial pain and headache: Overview, relevant neuroanatomy, sinogenic facial pain and headache. Overview, Relevant Neuroanatomy, Sinogenic. Web.
Cluster Headache Awareness Day – 21 march. International Headache Society. (2023). Web.