APPROACH TO THE PATIENT Headache
Headache is among the most common reasons that pts seek medical attention. Headache can be either primary or secondary (Table 55-1). First step—distinguish serious from benign etiologies. Symptoms that raise suspicion for a serious cause are listed in Table 55-2. Intensity of head pain rarely has diagnostic value; most pts who present to emergency ward with worst headache of their lives have migraine. Headache location can suggest involvement of local structures (temporal pain in giant cell arteritis, facial pain in sinusitis). Ruptured aneurysm (instant onset), cluster headache (peak over 3–5 min), and migraine (onset over minutes to hours) differ in time to peak intensity. Provocation by environmental factors suggests a benign cause.
Complete neurologic exam is important in the evaluation of headache. If exam is abnormal or if serious underlying cause is suspected, an imaging study (CT or MRI) is indicated as a first step. Lumbar puncture (LP) is required when meningitis (stiff neck, fever) or subarachnoid hemorrhage (after negative imaging) is a possibility. The psychological state of the pt should also be evaluated since a relationship exists between pain and depression.
TABLE 55-1COMMON CAUSES OF HEADACHE |Favorite Table|Download (.pdf) TABLE 55-1COMMON CAUSES OF HEADACHE
|Primary Headache ||Secondary Headache |
|Type ||% ||Type ||% |
|Tension-type ||69 ||Systemic infection ||63 |
|Migraine ||16 ||Head injury ||4 |
|Idiopathic stabbing ||2 ||Vascular disorders ||1 |
|Exertional ||1 ||Subarachnoid hemorrhage ||<1 |
|Cluster ||0.1 ||Brain tumor ||0.1 |
TABLE 55-2HEADACHE SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER |Favorite Table|Download (.pdf) TABLE 55-2HEADACHE SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER
“Worst” headache ever
First severe headache
Subacute worsening over days or weeks
Abnormal neurologic examination
Fever or unexplained systemic signs
Vomiting that precedes headache
Pain induced by bending, lifting, cough
Pain that disturbs sleep or presents immediately upon awakening
Known systemic illness
Onset after age 55
Pain associated with local tenderness, e.g., region of temporal artery
A benign and recurring syndrome of headache associated with other symptoms of neurologic dysfunction in varying admixtures. Second to tension-type as most common cause of headache; afflicts ~15% of women and 6% of men annually. Diagnostic criteria for migraine are listed in Table 55-3. Onset usually in childhood, adolescence, or early adulthood; however, initial attack may occur at any age. Family history often positive. Women may have increased sensitivity to attacks during menstrual cycle. Classic triad: premonitory visual (scotoma or scintillations), sensory, or motor symptoms; unilateral throbbing headache; and nausea and vomiting. Most pts do not have visual aura or other premonitory symptoms and are therefore referred to as having “common migraine.” Photo- and phonophobia common. Vertigo may occur. Focal neurologic disturbances without headache or vomiting ...