202

HEADACHE

[vol. vi

Eye-stiain
or every part of the head but is often most severe in the frontal and
sifboccipital regions. In subtentorial tumours it is apt to radiate into
the back of the neck (see Vol. II, p. 630). It is intermittent, occurring at
first in bouts usually lasting an hour or two, often restricted to the
early morning. It is provoked or aggravated by physical effort, stooping,
or straining, and is often associated with vomiting. The other associated
symptoms are usually those of a cerebral tumour (see Vol. II, p. 627).
Examination of the fundi is essential, but the absence of papillocdema
is compatible with increased intracranial pressure of some standing
(see papilloedema). Headache of this type may also occur in an
exacerbation of arterial hypertension (see Vol. II, p. 511).
Headache due to eye-strain is as a rule dull in character, frontal or
supra-orbital in situation, is noticed at night or in the early morning,
and follows prolonged visual attention, often associated at the time
with a sense of undue effort. Supra-orbital headache on the affected
side may occur as the leading symptom of acute glaucoma (see Vol. V,
p, 580).
Dental caries Dental caries is a not uncommon cause of pain referred to the head,
the molar teeth being usually responsible. From the lower jaw the pain
is referred to the temple and may radiate upwards. When the diseased
tooth is in the upper jaw, pain in or behind the eye on that side may be
the prominent symptom.
Disease of
the nose and
accessory
sinuses
Otitis media
Extra-dural
abscess
The headache of frontal sinusitis is often severe and throbbing and is
referred to the supra-orbital region on one or both sides. When the
infection is acute, as in the course of coryza, the pain is continuous and
aggravated by physical effort and bright light. A chronic empyema of
one frontal sinus may cause headache referred to that side, which
occurs in bouts lasting several days, on each of which the pain begins
almost at the same hour, usually in the mid-morning, and lasts until
in id-afternoon. Chronic infection of the ethmoidal cells or the sphenotdal
sinuses may cause pain of an aching character, referred to the brow
or eye on one or both sides, occurring in bouts, and aggravated or
provoked either by physical or mental effort, the latter especially if
eye-strain is involved. Occipital headache also may occur in sphenoidal
sinusitis (see accessory sinuses of the nose, Vol. I, p. 77). Obstruc-
tion of the nasal passages in the absence of inflammation has, in my
opinion, been saddled with an undue share of responsibility for headache.
Headache in, association with otitis media (see Vol. IV, p. 412) suggests
some deep extension of the infection. Involvement of the mastoid cells
alone does not as a rule cause headache. When the petrous bone is
affected, and especially if its apex is involved, pain occurs of a boring
or shooting character, referred to the temple and brow, intermittent,
and often, worse at night. Extra-dural abscess in the middle fossa
causes headache of similar type and distribution. In extra-dural abscess
of the posterior fossa the pain is referred mainly to the suboccipital
region but may radiate forwards as far as the brow. The headache of
cerebral or of cerebellar abscess (see Vol. II, p. 598) is of the same kind