The commonest headaches are tension headaches which are comparatively mild and often feel like a tight band around the head or heaviness of the head. They often occur later during the day and may be precipitated by a bad day in the office, a fight with a loved one or worry about some issue. All one needs to do is to take it easy, relax your mind, and if needed take some paracetamol and sleep it off. Such headaches have often been present for a long time and can be correlated with a stressful situation. In between these headache episodes the person is usually absolutely normal.
Migraines and other vascular headaches are usually more severe and are characterized by intense, pulsating throbbing pain, often accompanied by nausea and vomiting and the patient has extreme sensitivity to light and noise. They may be localised to one side of the head but more commonly may affect both sides. They occur in young adults and the intensity and frequency reduce when the patient becomes forty or fifty. A characteristic feature is the episodic nature of the headache which is severe and lasts for several hours or even for a couple of days. A variety of drugs are available to abort an acute attack, to alleviate the symptoms if an acute attack has come and to reduce the occurrence of the acute attacks if they are frequent.
While most headaches do not have serious consequences and are not fatal, in certain cases they may signal a serious health condition. Brain infections like meningitis may present with severe headache, vomiting, seizures and alteration of sensorium. The infection could be acute usually caused by a bacteria, may have a short history of a few days and rapid progression of headache with high fever. A chronic meningitis could have a longer history of several weeks or months and the progression is slow with low grade fever. This is commonly caused by tuberculosis or fungal infection. Both acute and chronic meningitis are associated with stiffness of the neck and painful restriction of neck movements.
Brain aneurysms and headaches
An aneurysm is a weak spot or ballooning in the blood vessels of the brain. It can leak or rupture – causing bleeding on the surface of the brain (subarachnoid hemorrhage) or in the brain tissue (intracerebral hematoma). At the time of the rupture the person has a sudden and severe headache often described as the worst ever headache experienced. This is often associated with neck stiffness and vomiting. If the bleeding is severe it may cause the patient to lose consciousness or even die suddenly. The hallmark of the headache caused by aneurysm rupture is the hyperacute sudden onset in a few seconds or minutes. A small unruptured brain aneurysm may not exhibit any symptoms and therefore remains undetected. A larger unruptured aneurysm may create pressure on brain tissues and nerves, causing pain or a neurological deficit.
There are two common treatment options for a ruptured brain aneurysm:
• Surgical clipping is a procedure to close off an aneurysm. This involves removing a section of the skull to access the aneurysm and locate the blood vessel that feeds it. A tiny metal clip is then placed on the neck of the aneurysm to stop the flow of blood in the aneurysm while maintaining onward blood flow through the vessel.
• Endovascular coiling is a less invasive procedure as compared to surgical clipping. It involves the insertion of a catheter (hollow plastic tube) into an artery, usually in the groin area and threading it through the vessels to the brain vessel hosting the aneurysm. Then detachable coils are inserted to completely fill the aneurysm from inside – so that no blood flow occurs into the aneurysm resulting in its occlusion.
The above procedures can also be used to seal an unruptured brain aneurysm as well and helps prevent future rupture. This is the type of headache which needs immediate treatment.
Brain tumour and headaches
A brain tumour is a mass or growth of abnormal cells in the brain. It can be cancerous (malignant) or noncancerous (benign). Brain tumours can originate in the brain (primary brain tumours), or cancer can begin in other parts of the body and spread to the brain (secondary or metastatic brain tumours). The skull is a closed compartment and when the tumour grows and occupies space, it results in increased pressure on the inside of the skull resulting in headache. And as the tumour grows the pressure increases and the headache increases in intensity and frequency. Headache is a common symptom of brain tumour and these are worse in the morning and often wake a person up from sleep – unlike other headaches which are worse in the evenings. Headaches associated with a brain tumour also increase due to coughing, sneezing or exercise. They are often accompanied by vomiting or visual blurring and double vision. The presence of epilepsy or seizures may also indicate a serious cause of the headache. The patient also may have neurological deficits including weakness or numbness of an arm or leg, speech difficulty, hearing problems or behaviour changes. Important to differentiate the headache of a brain tumour from a simple headache is the presence of persistent pain which continues to increase with time, the early morning onset and presence of associated neurological symptoms described above. The diagnosis of the brain tumour is easily established with modern MRI imaging of the brain.
The treatment for brain tumour depends on the type, size, and location of the tumour. Surgery is the primary modality of treatment of most brain tumours especially if large in size. The aim is total removal of the tumour without causing any fresh deficit. While this is achievable in most benign tumours – it is not always possible because of proximity of tumour to a critical vessel or nerve. For malignant brain tumours – even if we remove all the visible tumour – residual tumour cells may persist in the depth which are not visible even with the microscope. These would need to be treated with radiation therapy and chemotherapy – which for brain tumours is usually a tablet and is easily tolerated. Not all tumours need surgery though and some small brain tumours can be treated with Cyber Knife radiosurgery – which is the non-invasive delivery of highly focussed radiation beams onto the tumour without opening the head. This is also used for small residual tumours after surgery and for recurrent tumours. A particular type of secretory pituitary adenoma may be treated primarily by medical therapy.
Surgery for brain tumours has advanced tremendously with the advent of newer technology. Neuro-navigation is a computer assisted technique of knowing exactly where the tumour is and where our instrument has reached at any point during surgery (similar to the GPS in our car which tells us where we are at any point of time). The presence of an intraoperative MRI machine in the operation theatre helps us to assess the completeness of tumour removal during the surgery and to do more removal if needed. The use of operating microscope, high speed drills and the ultrasonic aspirator are standard adjuncts in today’s world. Preoperative embolization (blockage) of tumour vessels is done to reduce the vascularity of the tumour and reduce blood loss during surgery. Neuro-endoscopes are routinely used to make the surgery minimally invasive. Intraoperative neuro-monitoring is used to preserve neural function. The application of all these adjuncts has made the removal of brain tumours so much safer and more reliable.
Dr V. P. Singh, Chairman Neurosciences, Medanta – the Medicity