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of the eye, ear, nasal cavities, and paranasal sinuses; (3) intracranial venous sinuses and their large tributaries, especially pericavernous structures; (4) parts of the dura at the base of the brain and the arteries within the dura and pia-arachnoid, particularly the proximal parts of the anterior and middle cerebral arteries and the intracranial segment of the internal carotid artery; (5) the middle meningeal and super cial temporal arteries; and (6) the optic, oculomotor, trigeminal, glossopharyngeal, vagus, and rst three cervical nerves Interestingly, pain is practically the only sensation produced by stimulation of these structures; the pain arises in the walls of small blood vessels containing pain bers (the nature of vascular pain is discussed further on) Of importance also are the reference sites of pain from the aforementioned structures Pain impulses that arise from distention of the middle meningeal artery are projected to the back of the eye and temporal area Pain from the intracranial segment of the internal carotid artery and proximal parts of the middle and anterior cerebral arteries is felt in the eye and orbitotemporal regions The bony skull, much of the pia-arachnoid and dura over the convexity of the brain, the parenchyma of the brain, and the ependyma and choroid plexuses lack sensitivity The pathways whereby sensory stimuli, whatever their nature, are transmitted to the central nervous system (CNS) are the trigeminal nerves, particularly their rst and, to some extent, second divisions, which convey impulses from the forehead, orbit, anterior and middle fossae of the skull, and the upper surface of the tentorium The sphenopalatine branches of the facial nerve convey impulses from the naso-orbital region The ninth and tenth cranial nerves and the rst three cervical nerves transmit impulses from the inferior surface of the tentorium and all of the posterior fossa Sympathetic bers from the three cervical ganglia and parasympathetic bers from the sphenopalatine ganglia are mixed with the trigeminal and other sensory bers The tentorium roughly demarcates the trigeminal and cervical innervation zones The central sensory connections, which ascend through the cervical spinal cord and brainstem to the thalamus, are described in the preceding chapter To summarize, pain from supratentorial structures is referred to the anterior two-thirds of the head, ie, to the territory of sensory supply of the rst and second divisions of the trigeminal nerve; pain from infratentorial structures is referred to the vertex and back of the head and neck by the upper cervical roots The seventh, ninth, and tenth cranial nerves refer pain to the naso-orbital region, ear, and throat There may be local tenderness of the scalp at the site of the referred pain Dental or temporomandibular joint pain may also have cranial reference With the exception of the cervical portion of the internal carotid artery, from which pain is referred to the eyebrow and supraorbital region, and the upper cervical spine, from which pain may be referred to the occiput, pain due to disease in extracranial parts of the body is not referred to the head There are, however, rare instances of angina pectoris that may produce discomfort at the cranial vertex or adjacent sites and, of course, in the jaw.

Our understanding of headache has been greatly augmented by observations made during operations on the brain (Ray and Wolff) These observations inform us that only certain cranial structures are sensitive to pain: (1) skin, subcutaneous tissue, muscles, extracranial arteries, and periosteum of the skull; (2) delicate structures

The studies of Ray and Wolff demonstrated that relatively few mechanisms are operative in the genesis of cranial pain More speci cally, intracranial mass lesions cause headache only if in a position to deform, displace, or exert traction on vessels and dural structures at the base of the brain, and this may happen long before

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NONE This is the default setting and disables buffer cache reads from being recorded in the redo TYPICAL Buffer cache reads involving read-write tablespaces are recorded in the redo FULL All buffer cache reads are recorded in the redo, including reads on read-write and read-only tablespaces

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