Management of complaints of headache.
Has Head Trauma Occurred?
If recent head trauma has occurred, evaluation of this problem takes precedence (Chapter 22).
Patients may have headache following one or more grand mal seizures. However, because the seizures may themselves be due to serious underlying disease (eg, subdural hematoma), evaluation of this problem takes precedence (Chapter 19).
Are There Focal Neurologic Abnormalities?
The presence of new focal neurologic abnormalities with headache, especially if papilledema is present as well, is strongly suggestive of a mass lesion (tumor, hematoma, abscess). Computed tomography (CT) scan or magnetic resonance imaging (MRI) should be done as soon as possible to make the diagnosis. Further evaluation is discussed in Chapter 37.
Is Headache New or of Acute Onset?
The single most important item of information to obtain from a patient with headache is whether the headache is new or acute in onset. A new headache is one occurring in a patient without a history of headaches, or a novel pattern or quality of pain in a patient with a history of headaches. A headache that is acute in onset is far more likely to have underlying pathology that may be life-threatening requiring prompt investigation.
Is the Complaint Consistent with Meningitis or Meningeal Irritation?
If the headache is acute or subacute in onset, subarachnoid hemorrhage or meningitis must be suspected. The usual manifestations are signs of meningeal irritation (stiff neck; positive Kernig and Brudzinski signs) and fever. These findings may be minimal or even absent in very young or very old patients. Seizures, confusion, or coma may be present as well. Subarachnoid hemorrhage should be strongly suspected in a patient with abrupt onset of headache that is unique to the patient's experience, especially if meningeal irritation or focal neurologic findings are present. An emergency CT scan is the initial test of choice. However, as many as 2% of patients with subarachnoid hemorrhage can have a normal CT scan within the first 12 hours after the hemorrhage begins. If the diagnosis is unclear, lumbar puncture should be performed.
Meningitis should be strongly suspected in a patient who presents with headache accompanied by fever, especially if signs of meningeal irritation are present. Antibiotic therapy should be started as soon as possible (based on microorganisms most common for each age group) before the CT scan or lumbar punctures are performed (Chapter 42). However, if there are signs of focal neurologic findings in a patient with fever, a brain abscess should be suspected and the lumbar puncture (but not antibiotics) should be delayed until a CT scan is performed.
Is Headache Due to Hypertensive Encephalopathy or Preeclampsia-Eclampsia?
Moderate elevations of blood pressure alone seldom cause headache; however, severe hypertension as seen in hypertensive crises and eclampsia can be associated with headache. If hypertension is present and the patient is pregnant or has signs of cerebral dysfunction (confusion, obtundation, or coma) or other end-organ damage (retinitis; nephritis with proteinuria), a life-threatening emergency exists.
Note: In pregnancy, a slight increase in blood pressure may be more significant than in the nonpregnant patient. See Chapter 34 (see Hypertensive Crisis) or Chapter 38 (see Eclampsia).
Is This Temporal Arteritis?
Temporal arteritis is a rare but treatable disease with serious sequelae that must be considered in every elderly patient with new headache. The principal manifestations are headache with temporal artery tenderness (not found in every case) and a markedly elevated erythrocyte sedimentation rate. Sudden irreversible monocular blindness may occur. If this condition is suspected, immediate treatment with steroids is indicated and hospitalization should be considered to confirm the diagnosis by means of temporal artery biopsy.
Is Headache Due to Disease in Paracranial Structures?
New or acute headaches are often caused by disease in the eyes, ears, sinuses, or teeth. Look carefully for iritis or acute glaucoma (Chapter 31) or for sinusitis, otitis media, or dental caries or abscess (Chapter 32). Treatment should be focused on the primary condition.
Are There Multiple Patients from the Same Vicinity?
Multiple patients from the same vicinity with complaint of headache suggest carbon monoxide poisoning or other toxin exposure. Patients should be questioned specifically about heating sources (eg, gas heat or oven), burning materials (eg, charcoal) in poorly ventilated areas, use of household cleaners, or other chemical exposure. Specific treatment of carbon monoxide poisoning and other toxin exposure is discussed in Chapter 47.
Even after careful initial history and physical examination, the diagnosis may not be apparent in the patient with new headache. Patients with recent onset of new headache should be hospitalized if there is any suspicion of a life-threatening process. Increasing severity of subacute headache over days or weeks, even without focal signs, suggests serious intracranial disease, and the patient should undergo appropriate diagnostic procedures. Subacute headaches without progressive symptoms and chronic headaches may be referred and evaluated on a nonemergency basis.
Bederson JB, Connolly ES, Batjer HH et al: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009;40:994–1025
Lipton RB, Bigal ME, Steiner TJ, Silberstein SD, Olesen J: Classification of primary headaches. Neurology 2004;63:427–435
Somad D, Meurer W: Central nervous system infections. Emerg Med Clin Am ...