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INVESTIGATIONS OF HEADACHES: ARTERIOGRAPHY AND AIR ENCEPHALOGRAPHY
These investigations reveal a good deal because the size and shape of the blood vessels can be seen. This is not only important with someone at risk from a stroke, when a blockage or narrowing of an artery can be revealed and treated, but also because other abnormalities of the vessels can be seen, for example, a balloon-like distension (aneurysm) found at the junction of two vessels making up the circle of Willis. This can cause headache as well as pressure on sensitive structures leading to paralysis of one of the cranial nerves. Small leaks from such an aneurysm, or tiny expansions of it, can cause headaches resembling migraine. If it bursts, the consequent hemorrhage can be catastrophic.
Another abnormality is a growth of blood vessels rather like the strawberry birthmark seen on the skin. These are called arteriovenous malformations and vary in size; their presence will be suspected if the doctor hears a murmur, the noise of turbulent blood. These malformations cause a number of symptoms; e.g. epilepsy or hemorrhage. They may occasionally cause weakness of one side of the body, and can also be associated with a migraine-like syndrome, as in the following case:
A 24-year-old man came to the migraine clinic complaining of headache over the right side of his head associated with usual symptoms of classical migraine. Careful examination revealed no abnormality and skull X-rays, EEG, and isotope brain scan were all normal. The condition was treated as migraine and the patient responded well. Within a few weeks he collapsed at work having had a subarachnoid hemorrhage. Arteriography revealed a small arteriovenous malformation in the front part of the brain. He was operated on, the malformation successfully removed and he suffered no further headaches.
The cerebrospinal fluid is produced in spaces within the brain (the ventricles) and circulates through to the surface of the brain where it bathes the brain and spinal cord and is then re-absorbed. Air encephalography is performed by replacing the cerebrospinal fluid obtained by lumbar puncture with air. The air bubble enters the ventricles and, being of a different density to brain and cerebrospinal fluid, is seen as a dark area on the X-ray; any abnormalities in brain structure will be clearly shown.
Following encephalography the patient must lie flat for a day to prevent the development of headache which is caused by traction on the dura as the brain sags slightly because of low pressure of the cerebrospinal fluid. (A similar headache may be experienced when the patient is dehydrated, or as part of the ‘hangover’ following excessive alcohol intake.)
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