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intracranial pressure rises In fact, arti cially raising the intraspinal and intracranial pressure by the subarachnoid or intraventricular injection of sterile saline solution does not consistently result in headache This has been interpreted to mean that raised intracranial pressure does not cause headache a questionable conclusion when one considers the relief of headache in some patients that follows lumbar puncture and lowering of the cerebrospinal uid (CSF) pressure, particularly after subarachnoid hemorrhage Actually, most patients with high intracranial pressure complain of bioccipital and bifrontal headaches that uctuate in severity, probably because of traction on vessels or dura Dilatation of intracranial or extracranial arteries (and possibly sensitization of these vessels), of whatever cause, is likely to produce headache The headaches that follow seizures, infusion of histamine, and ingestion of alcohol are probably all due to cerebral vasodilatation Nitroglycerin, nitrites in cured meats ( hot-dog headache ), and monosodium glutamate in Chinese food may cause headache by the same mechanism It seems probable that the throbbing or steady headache that accompanies febrile illnesses has a vascular origin as well; it is likely that the increased pulsation of meningeal vessels activates pain-sensitive structures within their walls or around the base of the brain Certain systemic infectious agents, enumerated further on, seem to have a tendency to cause severe headache The febrile headache may be generalized or predominate in the frontal or occipital regions and is much like histamine headache in being relieved on one side by carotid or super cial temporal artery compression and on both sides by jugular vein compression It, like migraine, is increased by shaking the head A similar mechanism may be operative in the severe, bilateral, throbbing headaches associated with extreme rises in blood pressure, as occurs with pheochromocytoma, malignant hypertension, sexual activity, and in patients being treated with monoamine oxidase inhibitors Mild to moderate degrees of hypertension, however, do not cause headaches despite a popular notion to the contrary So-called cough and exertional headaches may also have their basis in the distention of intracranial vessels For many years, following the investigations of Harold Wolff, the headache of migraine was attributed to dilatation of the extracranial arteries Now it appears that this is not a constant relationship and that the headache is of intracranial as much as extracranial origin, perhaps related to the sensitization of blood vessels and their surrounding structures Activation of the trigeminovascular system (the trigeminal nerves and the blood vessels they supply), leading to sterile in ammation, has also been assigned a role in the genesis of migraine headache These and other theories of causation are summarized by Cutrer and discussed further on in this chapter in the sections on migraine With regard to cerebrovascular diseases causing head pain, the extracranial temporal and occipital arteries, when involved in giant-cell arteritis (cranial or temporal arteritis), give rise to severe, persistent headache, at rst localized on the scalp and then more diffuse With occlusion or dissection of the vertebral artery, the pain is in the upper neck or postauricular; basilar artery thrombosis causes pain to be projected to the occiput and sometimes to the forehead The ipsilateral eye and brow and the forehead above it are the most common sites of projected pain from dissection of the carotid and occlusion of the stem of the middle cerebral arteries Expanding or ruptured intracranial aneurysms may cause pain projected from the posterior communicating artery to the eye.

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Infection or blockage of paranasal sinuses is accompanied by pain over the affected maxillary or frontal sinuses Usually it is associated with tenderness of the skin in the same distribution Pain from the ethmoid and sphenoid sinuses is localized deep in the midline behind the root of the nose or occasionally at the vertex (especially with disease of the sphenoid sinus) or adjacent part of the cranium The mechanism in these cases involves changes in pressure and irritation of pain-sensitive sinus walls Sinus pain recurs and subsides periodically, depending on drainage from the sinus With frontal and ethmoidal sinusitis, the pain tends to be worse on awakening and gradually subsides when the patient is upright; the opposite pertains with maxillary and sphenoidal sinusitis These relationships are believed to disclose their mechanism; pain is ascribed to lling of the sinuses and its relief to their emptying, induced by the dependent position of the ostia Bending over intensi es the pain by causing changes in pressure, as does blowing the nose; during air travel, both earache and sinus headache tend to occur on descent, when the relative pressure in the blocked viscus rises Sympathomimetic drugs such as phenylephrine hydrochloride, which reduce swelling and congestion, tend to relieve the pain However, the pain may persist after all purulent secretions have disappeared, probably because of blockage of the ori ce by boggy membranes and absorption of air from the blocked sinus (vacuum sinus headaches) The condition is relieved when aeration is restored Headache of ocular origin, located as a rule in the orbit, forehead, or temple, is of the steady, aching type and tends to follow prolonged use of the eyes in close work The main faults are hypermetropia and astigmatism (rarely myopia), which result in sustained contraction of extraocular as well as frontal, temporal, and even occipital muscles Correction of the refractive error abolishes the headache Traction on the extraocular muscles or the iris during eye surgery will evoke pain Patients who develop diplopia from neurologic causes or are forced to use one eye because the other has been occluded by a patch often complain of frontal headache Another mechanism is involved in iridocyclitis and in acute glaucoma, in which raised intraocular pressure causes steady, aching pain in the region of the eye, radiating to the forehead As for headache in general, it is important that the eyes be refracted, but eyestrain is not as frequent a cause as one would expect from the wholesale dispensing of eyeglasses for its relief Headaches that accompany disease of ligaments, muscles, and apophysial joints in the upper part of the cervical spine are referred to the occiput and nape of the neck on the same side and sometimes to the temple and forehead These headaches have been reproduced in part by the injection of hypertonic saline solution into the affected ligaments, muscles, and zygoapophysial (facet) joints Such pains are especially frequent in late life because of the prevalence of degenerative changes in the cervical spine and tend also to occur after whiplash injuries or other forms of sudden exion, extension, or torsion of the head on the neck If the pain is arthritic in origin, the rst movements after the individual has been still for some hours are stiff and painful The pain of bromyalgia, a controversial entity, is evidenced by tender areas near the cranial insertion of cervical and other muscles There are no pathologic data as to the nature of these vaguely palpable and tender lesions, and it is uncertain whether the pain actually arises in them They may represent only the deep tenderness felt in the region of referred pain or the involuntary secondary protective spasm of muscles Sleep disturbance is often associated, as is depression Massage of muscles, heat, and injection of the tender spots with local anesthetic have.

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