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  1. Are there warning signs of a secondary headache that would require further imaging?

  2. Is the headache new or different?

  3. Is the headache brought on by exertion, sexual intercourse, coughing, or sneezing?

  4. Is the onset of the headache sudden or severe?

  5. Has the patient experienced antecedent head or neck trauma?

  6. Does she have any neurologic symptoms other than visual symptoms occurring only at the beginning of the headache syndrome?

  7. The patient described her typical migraine headaches.

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Case 87-1

A 25-year-old, right-handed woman with a 3-year history of headaches is admitted to the hospital for “pain control.” In the emergency department she had a negative noncontrast head computed tomographic (CT) scan and was prescribed a hydromorphone (Dilaudid) drip.

Does the patient have any other medical problems or risk factors for intracranial pathology?

Her past medical history and review of systems is otherwise negative. Her family history is positive for migraine.

What factors worsen the headaches?

Tension and stress triggered her headaches, typically worse 2 or 3 days before her menstrual period begins. Alcohol, chocolates and peanuts may aggravate her headache. She tried stopping the oral contraceptive and noticed no improvement in her headaches. Social history reveals that she is single and disabled from her headaches.

What medications has she tried?

She has tried many different medications, including analgesics, antidepressants, calcium channel blockers, and ß-blockers. The only medications that help her are sumatriptan taken subcutaneously and narcotics, currently hydrocodone at least one tablet a day. She has been taking alprazolam 10 mg three times a day for a couple of years. She also uses promethazine for nausea. Recently she is beginning to have daily headaches and has to make trips to the emergency department to get shots of meperidine.

What has been her work-up to date?

She has seen multiple neurologists. She has been treated with biofeedback and has seen a psychologists. She had multiple CT scans and magnetic resonance imaging (MRI) of her head.

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Complaints of headache represent a major health problem due to their prevalence, chronicity, and the cost of ruling out life-threatening or serious underlying pathology that may cause significant morbidity and mortality. Up to 4.5% of all emergency department visits may be attributed to symptoms of headache, and headache may be the fifth most common reason for primary care visits (following checkups, upper respiratory illnesses, back pain, and skin rashes). Loss of productivity due to headache is also substantial with an estimated cost of billions of dollars.

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The International Headache Society classifies headache as primary and secondary. Primary headaches account for at least 90% of all headaches and have benign outcomes. Primary headaches include migraine with or without aura, tension type headache, and less commonly, cluster headache. Some patients with a history of primary headaches have significant risk factors for developing secondary headaches. This chapter focuses on the diagnostic approach for the patient with headache in the ...

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