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Chapter 11: Neurology

Lisa Moore

HEADACHE

Diagnosis of Dangerous Causes of Headache

Consider imaging or further workup if the patient complains of one of these “red flag” symptoms. Table 11.1 summarizes key symptoms that may indicate a dangerous cause of headache.

image MNEMONIC

Red flag symptoms in patients with headache:

SNOOP

Systemic symptoms or illness

Neurologic symptoms or signs (papilledema, asymmetric cranial nerve or motor function, abnormal cerebellar function)

Onset recently or suddenly

Onset after age 40 years

Prior headache history that is different or progressive

Table 11.1Presentation of Dangerous Causes of Headaches
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Table 11.1 Presentation of Dangerous Causes of Headaches
SYMPTOM POSSIBLE CAUSE
Sudden onset of “The worst headache of my life.” Subarachnoid hemorrhage
Neck stiffness with severe headache Bacterial meningitis, subarachnoid hemorrhage
Sudden ↓ level of consciousness Intracranial bleed, intracranial mass
Progressively worsening headache Intracranial mass
Daily headaches that awaken the patient from sleep or are severe on arising in the morning Intracranial mass with ↑ ICP
Onset of headache after 40 years of age Intracranial mass
Progressive visual, motor, or balance disturbance, or cognitive changes Intracranial mass, vascular lesion
Onset of headache after age 50 years of age Temporal arteritis, intracranial mass

Migraine Headache

Symptoms/Exam

  • Recurrent headaches lasting 4 to 72 hours. To diagnose, at least two of the following characteristics must be present: unilateral distribution, pulsatile quality, severity limiting daily activities, and exacerbation by physical activity. One of the following characteristics must also be present: nausea or vomiting, photosensitivity, and sensitivity to noise or smell.

  • Migraine with aura is preceded by a reversible symptom indicative of focal cerebral dysfunction. Examples of auras include gradual onset and spread of scotomas, scintillations, and/or hemianopic field defects; unilateral paresthesias or numbness; unilateral weakness; and speech disturbance. It is possible to have aura symptoms with gradual onset and no subsequent headache.

  • Women who have migraine with aura should not use estrogen-containing contraceptives because of ↑ stroke risk.

image KEY FACT

Migraines are more common in women than in men, and typical age of onset is 10 to 30 years.

image KEY FACT

Benign causes of headache can usually be diagnosed without imaging or labs based on the history and lack of focal neurologic deficits.

Diagnosis

Based on symptoms, family history of migraines, and normal neurologic exam.

Management

  • Abortive therapy: NSAIDs, acetaminophen, triptans, ergotamines, and antiemetics. Narcotic analgesics used as a last resort.

  • Prophylaxis: β-blockers, calcium channel blockers, tricyclic antidepressants (TCAs), anticonvulsants. Avoidance or mitigation of triggers such as stress, missed meals, menses, and sleep deprivation.

Tension Headache

Most common type of chronic recurring headache.

  • Symptoms/exam: Presents as a ...

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