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of the eye, ear, nasal cavities, and paranasal sinuses; (3) intracranial venous sinuses and their large tributaries, especially pericavernous structures; (4) parts of the dura at the base of the brain and the arteries within the dura and pia-arachnoid, particularly the proximal parts of the anterior and middle cerebral arteries and the intracranial segment of the internal carotid artery; (5) the middle meningeal and super cial temporal arteries; and (6) the optic, oculomotor, trigeminal, glossopharyngeal, vagus, and rst three cervical nerves Interestingly, pain is practically the only sensation produced by stimulation of these structures; the pain arises in the walls of small blood vessels containing pain bers (the nature of vascular pain is discussed further on) Of importance also are the reference sites of pain from the aforementioned structures Pain impulses that arise from distention of the middle meningeal artery are projected to the back of the eye and temporal area Pain from the intracranial segment of the internal carotid artery and proximal parts of the middle and anterior cerebral arteries is felt in the eye and orbitotemporal regions The bony skull, much of the pia-arachnoid and dura over the convexity of the brain, the parenchyma of the brain, and the ependyma and choroid plexuses lack sensitivity The pathways whereby sensory stimuli, whatever their nature, are transmitted to the central nervous system (CNS) are the trigeminal nerves, particularly their rst and, to some extent, second divisions, which convey impulses from the forehead, orbit, anterior and middle fossae of the skull, and the upper surface of the tentorium The sphenopalatine branches of the facial nerve convey impulses from the naso-orbital region The ninth and tenth cranial nerves and the rst three cervical nerves transmit impulses from the inferior surface of the tentorium and all of the posterior fossa Sympathetic bers from the three cervical ganglia and parasympathetic bers from the sphenopalatine ganglia are mixed with the trigeminal and other sensory bers The tentorium roughly demarcates the trigeminal and cervical innervation zones The central sensory connections, which ascend through the cervical spinal cord and brainstem to the thalamus, are described in the preceding chapter To summarize, pain from supratentorial structures is referred to the anterior two-thirds of the head, ie, to the territory of sensory supply of the rst and second divisions of the trigeminal nerve; pain from infratentorial structures is referred to the vertex and back of the head and neck by the upper cervical roots The seventh, ninth, and tenth cranial nerves refer pain to the naso-orbital region, ear, and throat There may be local tenderness of the scalp at the site of the referred pain Dental or temporomandibular joint pain may also have cranial reference With the exception of the cervical portion of the internal carotid artery, from which pain is referred to the eyebrow and supraorbital region, and the upper cervical spine, from which pain may be referred to the occiput, pain due to disease in extracranial parts of the body is not referred to the head There are, however, rare instances of angina pectoris that may produce discomfort at the cranial vertex or adjacent sites and, of course, in the jaw.

Our understanding of headache has been greatly augmented by observations made during operations on the brain (Ray and Wolff) These observations inform us that only certain cranial structures are sensitive to pain: (1) skin, subcutaneous tissue, muscles, extracranial arteries, and periosteum of the skull; (2) delicate structures

The studies of Ray and Wolff demonstrated that relatively few mechanisms are operative in the genesis of cranial pain More speci cally, intracranial mass lesions cause headache only if in a position to deform, displace, or exert traction on vessels and dural structures at the base of the brain, and this may happen long before

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It s time to introduce some important concepts We know what a search problem is: its de ning characteristic is that any proposed solution can be quickly checked for correctness, in the sense that there is an ef cient checking algorithm C that takes as input the given instance I (the data specifying the problem to be solved), as well as the proposed solution S, and outputs true if and only if S really is a solution to instance I Moreover the running time of C(I, S) is bounded by a polynomial in |I|, the length of the instance We denote the class of all search problems by NP We ve seen many examples of NP search problems that are solvable in polynomial time In such cases, there is an algorithm that takes as input an instance I and has a running time polynomial in |I| If I has a solution, the algorithm returns such a solution; and if I has no solution, the algorithm correctly reports so The class of all search problems that can be solved in polynomial time is denoted P Hence, all the search problems on the right-hand side of the table are in P 239

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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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