Ординатура / Офтальмология / Английские материалы / The Eye Book A Complete Guide to Eye Disorders and Health_Cassel, Billig, Randall_2001

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cific. Your description of your pain and other symptoms, plus your doctor’s thorough questions, will help establish the type of headache and its cause (see box).

Your doctor may ask you to keep a headache diary, recording such things as the time of day, any events that happened just before the headache, and the duration. Also, if you have chronic, recurrent, or severe headaches, you may need a thorough physical checkup, plus blood tests, sinus X-rays, and a magnetic resonance imaging (MRI) scan of the head.

Tension Headaches

Most headaches are caused by tension. Your basic tension headache begins as the muscles tense up in the back of your head or neck. This pulling then radiates to both sides of your head and around front, to your forehead. This has been called a “bandlike” tightness, because it feels as if someone’s clamping a vise around your head. It can also occur in migraine sufferers, sometimes making it difficult to distinguish between the two types of headache. However, although the symptoms may be similar, tension headaches are always related to stressful moments. They don’t get worse or better if you turn your head or body a certain way, as migraines can. They usually aren’t affected by light or accompanied by photophobia (abnormal sensitivity to light) or other associated neurologic symptoms such as nausea, dizziness, loss of vision, numbness, or muscle weakness.

If it’s any comfort, you’re not alone. Almost everybody gets a tension headache at least once in a while. Also, this

Establishing the Type and Cause of a Headache

Here are a few questions you can expect your doctor to ask you about your headache:

•Where was the pain? In the temples? The top of the head?

•When did it start? How bad was it? (In other words, were you still able to function, or did you need to lie down?)

•How long did it last?

•How often do you get such headaches? Twice a month? Once a week?

•Do you have any other symptoms when you get a bad headache?

•Has any medication—aspirin, Advil, Tylenol, an antihistamine—helped or not helped?

•Does anything seem to trigger it—stress, reading, medications, certain seasonings or foods (such as any food or drink containing caffeine)?

•Do the headaches seem to occur at a certain time of day?

•Does the headache wake you up from sleep?

•Do you awaken in the morning with the headache?

•Does it vary with changes in position? (A yes to these last three questions may suggest headaches due to elevated intracranial pressure.)

•Does anyone else in your family suffer from bad headaches? (A family history of headaches can help your doctor diagnose a migraine.)

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major cause of headaches, and finding the right prescription for nearsightedness, farsightedness, or astigmatism rarely puts an end to persistent headaches. Therefore, before simply writing you a new prescription, your doctor needs to make sure something else isn’t going on here, either another medical problem or another eye problem. You’ll need a complete eye evaluation, including a dilated retinal examination, to rule out other eye ailments, including conjunctivitis, corneal abrasions and ulcers, iritis, cyclitis, posterior scleritis, acute closedangle glaucoma, optic neuritis, eye tumors, and other eye inflammatory diseases. All of these can cause headaches or eye pain. (See the Index for specific page references to these problems.)

How do you know if it’s a refractive headache? Does it happen when your eyes are hard at work—for example, reading, doing needlework, or working on an intricate ship model? Since these headaches are usually due to someone’s need for glasses—in most cases reading glasses—or the need for a different prescription, you may experience “tired eyes,” or discomfort around or behind the eyes after prolonged reading or computer work.

You don’t get refractive headaches first thing in the morning, when your eyes are relatively refreshed. You don’t get them when your eyes are relaxed—on weekends, for example, when you’re leisurely gardening in your backyard. Headaches related to the eyes are dull and aren’t associated with the nausea, vomiting, or “visual phenomena” found in migraines. However, they can lead to a tension headache from the anxiety they cause.

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Migraines

Believe it or not, although the name is synonymous with headaches, you don’t have to have a headache to have a migraine. You could just see things—geometric shapes, flashbulbs, jagged lines, heat waves, sparkling, watery images, “Swiss cheese” patterns, and other phenomena.

Nobody really knows what causes migraines. However, scientists think they’re caused by changes in the blood vessels of the brain. They can be triggered by a dazzling variety of stimuli, including stress, caffeine (coffee, tea, cola, chocolate), cheese, nuts, red wine, MSG (monosodium glutamate, common in Chinese food), or birth control pills; all of these are known to cause the brain’s cerebral blood vessels to constrict, or clench. This constriction can decrease blood flow to certain parts of the brain, causing a relative ischemia, or lack of oxygen. Then, in response, the cerebral blood vessels compensate by dilating: they stretch the surrounding brain tissue. All of this, in people who are prone to migraines, can cause chaos: the visual problems mentioned above, or feelings of nausea and dizziness, or a terrible, disabling headache, or combinations of these symptoms. Symptoms may even change from episode to episode, and many people who experience visual or other migraine symptoms never even get a headache. There seem to be infinite variables at play here.

Migraines can strike at any age. Generally, they’re clas-

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sified into four types: common, classic, cluster, and complicated.

Common Migraines

Common migraines are severe headaches that usually begin on one side of the head as pounding, stretching, or throbbing. They can spread to involve half or all of the head. The intense headache pain can even occur behind the eyeball, mimicking sinus or other eye problems. Many sufferers of common migraine have a premonition that one’s about to hit; this is called an aura, and it can come in the form of visual events, a mood change, a series of yawns, trouble with speech, or other neurologic symptoms.

Common migraines can be extremely incapacitating headaches, lasting hours or even days, often causing people to seek refuge in a quiet, dark room until the pain goes away. They may be associated with nausea, conjunctival redness, watery eyes, a “foreign-body” sensation in the eyes, or ultrasensitivity to light.

Classic Migraines

Classic migraines have better-defined warning symptoms than common migraines. These migraines also tend to include visual or “sensory-motor” disturbances, such as numbness or weakness of an arm or leg, before or during the headache. Sufferers describe a visual aura such as shining lights, flashbulbs, sparkles, geometric patterns, zigzag lines, heat waves, or “Swiss cheese” areas

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of vision loss. These visual phenomena can last minutes, hours, or even days. People may even experience a buildup, crescendo, or march of these phenomena—in other words, the little wavy lines may begin as a small area off to one side of your vision and gradually increase until they involve half or all of your visual field. Sometimes the aura before the headache isn’t visual; instead, people may experience numbness around the mouth, an unusual sensation over half of the body, dizziness, or even temporary disorientation. Classic migraine attacks may modify their presentation over the years: as they age, some people may still experience the visual or sensorymotor aura but, mercifully, forgo the headache.

Like common migraines, classic migraines affect men and women equally, tend to occur at any age, and often run in families; also, a history of motion sickness is not uncommon. For most sufferers of classic migraines, mild over-the-counter analgesics do absolutely nothing; stronger medications are often needed. As with other forms of migraines, attacks can be precipitated by a variety of things, including stress, bright light, loud noise, caffeine (coffee, tea, cola, chocolate), certain spices and seasonings, certain foods, unusual diets, and medications such as birth control pills. (Identifying the precipitating event is an important part of the treatment, as you may imagine.)

Cluster Migraines

Cluster migraines are five times more likely to occur in men than women, most commonly in middle age.

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These are often unilateral headaches (occurring on only one side), described as excruciating, burning, sharp, or a deep ache. They begin and end quickly, lasting only one or two hours. However, they don’t stay away long; on really bad days they can return several times within a twenty-four-hour period (hence the term cluster). Eyerelated symptoms may include a droopy eyelid, tearing, and a red eye. The droopy eyelid goes away when the headache’s gone.

Complicated Migraines

“Complicated migraines” is a general classification for a variety of temporary or permanent symptoms and patterns. The typical migraine headache may not always be present. Complicated migraines are often associated with eye problems; the three forms of complicated migraines most often associated with the eyes are acephalagic, ocular (also called retinal or ophthalmic migraines), and ophthalmoplegic.

Acephalagic migraines usually have visual symptoms but, by definition, don’t come with a headache. Visual symptoms can be like those reported in classic migraines but may also include blurred vision, temporary blindness in one or both eyes, and abnormal pupil dilation (which you can see in a mirror). Other symptoms may include numbness or tingling, difficulty with speech or reading, dizziness, confusion, and trouble hearing.

Ocular (retinal or ophthalmic) migraines involve a temporary or even permanent loss of vision in one eye. The vision loss may last from seconds to hours, but it

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usually goes away in less than half an hour. It tends to affect people under age forty with a strong history of common or classic migraines. Permanent visual defects are very rare but can occur after repeated attacks. As with all types of migraines, the associated visual and neurologic aura almost always goes away. Although the retina and optic nerve are usually normal after these attacks, some people go on to develop ischemic optic neuropathy (see chapter 16), central and branch retinal artery occlusions, central retinal vein occlusion, and central serous retinopathy. (As you may imagine, if there’s vision loss in one eye but no other evidence of eye damage, this form of migraine can be very difficult to distinguish from amaurosis fugax, discussed above.) Although we don’t know why these particular headaches affect vision, some scientists believe that in some people, as the cerebral blood vessels constrict during a migraine, so do the major blood vessels supplying the retina and optic nerve.

Ophthalmoplegic migraines: In this form of complicated migraine, the attack also strikes the nerves that control the eye’s muscles, commonly resulting in a droopy eyelid, trouble raising the eyelid, and trouble moving the eye from side to side. Although, as with ocular migraines, these problems are usually temporary, they can in rare cases become permanent after repeated attacks.

Here too, as with other forms of complicated migraines, ophthalmoplegic migraines are a “diagnosis of exclusion.” In other words, we need a complete medical and eye evaluation to rule out every other possible

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cause—including a blood clot, myasthenia gravis, thyroid eye disease, or a tumor—before we can be sure this is what’s causing the problem.

Giant Cell Arteritis

Giant cell arteritis can cause headaches, tenderness in the temples, and other symptoms. See chapter 17 for a full description of this medical emergency.

Brain Tumors and Headaches

How do we know it’s a brain tumor? We don’t, at first. Although headaches occur in an estimated two-thirds of people with brain tumors—and for many, headaches are the first symptom of a problem—there is no “classic brain-tumor headache.” In fact, in many cases the pain isn’t even on the same side of the head as the tumor.

These chronic headaches characteristically are intermittent, dull (not throbbing), and moderate in severity; they tend to get worse with exercise or positional changes, and they don’t respond to headache medications. They may be associated with nausea and vomit- ing—which, again, makes them tough to distinguish from certain forms of migraine. Some people with brain tumors can be awakened from sleep by their headaches.

Again, we make the “diagnosis of exclusion,” which involves a complete medical and eye examination, often including brain imaging. (For more on brain tumors and other visual problems, see below.)