Routine diagnostic tests include a CBC to rule out severe anemia, a sedimentation rate to rule out temporal arteritis, a chemistry panel to rule out liver and kidney disease, a VDRL test to rule out central nervous system syphilis, an x-ray of the sinuses to rule out sinusitis, and an x-ray of the cervical spine to exclude cervical spondylosis. A chest x-ray should also be done to rule out the possibility of metastatic neoplasm. A tonometry study may be done if glaucoma is suspected.
If there are focal neurologic signs, referral should be made to a neurologist or neurosurgeon as soon as possible. If one is not readily available, a CT scan or MRI may be done, the CT scan being the preferred procedure if the expense is a consideration.
If there is nuchal rigidity, a CT scan should be done to rule out a space-occupying lesion before proceeding with a spinal tap. If the CT scan is negative, a spinal tap can be done, and this will ascertain whether there is intracranial bleeding or meningitis. It is usually best to refer the patient to a neurologist or neurosurgeon if there is nuchal rigidity.
If the headaches are chronic and episodic, and there are no focal neurologic signs, papilledema, or nuchal rigidity, an imaging study can be postponed for a while until the response to treatment is evaluated. However, if the response to treatment is poor, one should not hesitate to order a CT scan or MRI.
Difficult cases of headache should also be studied with 24-hr blood pressure monitoring, a 24-hr urine for catecholamines, and lumbar puncture to diagnose central nervous system lues. Histamine phosphate 0.5 cc subcutaneously may help diagnose cluster headaches. Response to beta-blockers may help diagnose migraine. Cerebral angiography may be necessary to diagnose aneurysms and arteriovenous malformations. Patients with chronic headache unresponsive to therapy should be referred to a psychiatrist.
Migraine
–Recurring headache with throbbing,
pulsating pain; nausea and vomiting;
photophobia, phonophobia
–Family history of migraine
–Improvement with rest/sleep
–Without aura (common migraine) 85%
–With aura (classic migraine) 15%
–Frequently bilateral pain in children
–Aura usually develops over 5 minutes and is
most commonly visual
–Migraine is an episodic disorder
–Chronic daily headache is not migraine
-
Tension headache
-
Pseudotumor cerebri
–Elevated ICP with no masses or
abnormalities in CSF or labs
-
Cluster headache
–Unilateral nonthrobbing, periorbital pain
–May have ipsilateral conjectival injection,
lacrimation, rhinorrhea
-
Subarachnoid hemorrhage
–Sudden paroxysmal headache
–Meningeal signs
–An emergency requiring CT and LP
-
Increased intracranial pressure
–Tumor, abscess, hydrocephalus, hemorrhage
-
Sinusitis, otitis
-
Dental disease
-
Systemic infection
-
TMJ disease
-
Postconcussive syndrome
-
Trigeminal neuralgia
-
Mitochondrial disorders
-
Venous sinus thrombosis
-
Meningitis/encephalitis
-
CSF leak, post-lumbar puncture
-
Hypertensive crisis
-
Trauma
-
Arteriovenous malformation
-
Stroke
-
Toxins and medication
–Nitrites, cocaine, interferon, CO
-
Fever
-
Anemia
Workup and Diagnosis
-
History
–Duration (recurrent, progressive), frequency
–Time of onset and duration
–Location and nature of pain, warning (aura)
–Factors that alleviate or exacerbate symptoms (e.g.,
stress)
–Nausea, vomiting, photophobia, phonophobia
–Family history, response to treatment
-
Physical exam
–Vital signs (temperature, blood pressure)
–Height, weight, head circumference
–Funduscopy (to rule out papilledema)
-
Neuroimaging (CT, MRI) is required for certain symptoms
–Short history of headache (<6 months) or age <5–6
years
–Worsening headaches, no response to treatment
–Deterioration in cognitive or motor function
–Short stature, macrocephaly
–Awakening at night or early morning
–Repeated morning vomiting
–Exacerbation by position change or cough
–Focal neurologic symptoms during headache
–Cluster headache in prepubertal children and
adolescent girls
–Systemic symptoms: Fatigue, weight loss
–Abnormal neurological exam
- Lumbar puncture with opening pressure
–Subarachnoid hemorrhage, pseudotumor, or meningitis
>>
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Source: In A Page: Pediatric Signs and Symptoms, 2007
HEADACHE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The patient presenting with a history of headaches is an exciting diagnostic challenge. If one approaches the challenge simply on the basis of what is common, the patient most likely has migraine or muscle traction headache. But, wait a minute! Shouldn’t we look for serious conditions such as brain tumor, meningitis, or subarachnoid hemorrhage to avoid a serious mistake and a malpractice suit? First, check for nuchal rigidity to rule out meningitis and subarachnoid headache. Next, do a careful neurologic examination to rule out a brain tumor or other space-occupying lesion. These steps are particularly important in a patient is experiencing his or her first serious headache. If there is nuchal rigidity or focal neurologic signs, it is wise to immediately refer the patient to a neurologist or neurosurgeon for further workup and possible hospitalization. The specialist will probably order a CT scan of the brain and follow that with a spinal tap if a subarachnoid hemorrhage or meningitis is suspected. It is clear that a CT scan should be done prior to a spinal tap if there are focal neurologic signs or papilledema. One other condition that must be considered in acute headache particularly in the elderly is temporal arteritis. A sedimentation rate will usually be positive but a neurology consult is axiomatic so that steroids can be started immediately.
In the patient with chronic or recurring headaches and no neurologic findings, it is wise to see the patient during the attack. Migraine and histamine headaches can be diagnosed by the response to sumatriptan by mouth or injection. If the headaches are due to chronic allergic or infectious rhinitis, relief can be had by spraying the turbinates with phenylephrine. Muscle traction headaches will often be relieved by occipital nerve blocks supporting the diagnosis. Compression of the superficial temporal artery will often relieve migraine temporarily supporting that diagnosis. Compression of the jugular veins will often give relief to post spinal tap headaches.
If the patient is seen between headaches, certain prophylactic measures may help establish the diagnosis. For migraine, β-blockers may be prescribed and if the headaches are prevented, there is good support for the diagnosis. A course of corticosteroids may be initiated in patients with histamine (cluster) headaches to help establish the diagnosis. Muscle relaxants and/or tricyclic drugs may be given to help diagnose muscle contraction headaches.
The diagnostic workup of chronic headaches might include a CT scan of the brain, x-rays of the sinuses, x-rays of the cervical spine and routine blood work. Certainly if headache persists after careful follow up, these need to be done.
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Source: Differential Diagnosis in Primary Care, 2007
Aura:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Obtain a thorough history of the patient’s headaches or seizure history, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Headache:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the past 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures or does he have a history of seizures?
Begin the physical examination by evaluating the patient’s level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP — a widened pulse pressure, bradycardia, an altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Headache:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis requires a history of recurrent headaches and physical examination of the head and neck. Such examination includes percussion, auscultation for bruits, inspection for signs of infection, and palpation for defects, crepitus, or tender spots (especially after trauma). Firm diagnosis also requires a complete neurologic examination, assessment for other systemic diseases — such as hypertension — and a psychosocial evaluation, when such factors are suspected.
Diagnostic tests include cervical spine and sinus X-rays, EEG, computed tomography scan — performed before lumbar puncture to rule out increased intracranial pressure (ICP) — or magnetic resonance imaging. A lumbar puncture isn’t done if there’s evidence of increased ICP or if a brain tumor is suspected because rapidly reducing pressure by removing spinal fluid can cause brain herniation.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Aura:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After providing emergency care, obtain a thorough history of the patient’s headaches or seizures, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Headache:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as eating certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?
Begin the physical examination by evaluating the patient’s level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—widened pulse pressure, bradycardia, altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness. (See Differential diagnosis: Headache, pages 392 and 393.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Headache:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the headache. What is the type of pain, its location, its duration, and its intensity? What symptoms precede or accompany the pain? Does anything trigger the headache or make the pain better or worse? Tell about a typical headache from beginning to end.
1. Migraine food triggers include alcohol, aged cheese, chocolate, and aspartame.
2. Approximately 20% to 30% of migraineurs will report an aura, typically visual in nature.
3. Patients with cluster headache report unilateral temporal headache, occurring generally once daily, usually in the evening and associated with ipsilateral nasal stuffiness and conjunctival injection.
4. Chronic daily headache (CDH) patients will describe headaches at least 10 to 15 days/month and usually report heavy use of relief drugs.
5. Red flags that might suggest intracranial pathology (section I.B) include a loss of consciousness, persistent visual loss, seizures, staggering, or hearing loss.
B. Chronology of the headache. Most primary headaches recur periodically for years, with only subtle changes over time. If the headache is getting worse, the cause might be psychosocial stressors, medication overuse, or evolving intracranial pathology (Table 2.5). Ask women whether the headache seems related to the menses. Past and current medication use and how they affect the headache can be important clues to headache severity and how the patient may respond to treatment.
C. Family history. Migraine headaches often exhibit a familial pattern; the causes of secondary headaches generally do not. Tension headache can represent a family pattern of reacting to stress.
D. Psychosocial aspects of the headache. What does the patient believe is the cause of the headache? What life events might be playing a role? How does the patient’s family react to the headache? Ask: “If you did not have the headache, how would your life be different?” The key to management of recurrent primary headaches often lies in the responses to these questions, which can reveal unanticipated stressors, secondary gain, or family discord.
E. Other information. Important data include use of tobacco, alcohol, or coffee; response to exercise; a history of head trauma; or exposure to toxic fumes or chemicals. Have there been symptoms of fever, or fatigue? Ask about depression, which is often seen in migraineurs.
Physical examination
A. Focused physical examination (PE). This should include vital signs (notably blood pressure) and an examination of the scalp; eyes, including funduscopic examination; ears; nose; paranasal sinuses; throat; and neck. A screening neurologic examination, including cranial nerves, coordination (finger-to-nose test), and deep tendon reflexes, is sufficient in most instances. In the migraineur, the examination findings should be all normal in the absence of a current headache; a positive finding warrants further testing (section IV).
B. Additional PE. Other PE maneuvers are appropriate if the medical history suggests specific secondary headache causes: palpation of the superficial temporal arteries (temporal arteritis), audiometry (acoustic neuroma), transillumination of the paranasal sinuses (“sinus headache”), or checking for nuchal rigidity plus Kernig’s and Brudzinski’s signs (meningeal irritation).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Headache:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Migraine
❑ Tension
❑ Acute sinusitis
❑ Acute glaucoma
❑ Postconcussive
❑ Cluster
❑ Meningitis
❑ Drugs
❑ Hypoglycemia
❑ Benign exertional headache
❑ Temporomandibular joint inflammation
❑ Subdural hematoma
❑ Subarachnoid hemorrhage
❑ Acute epidural hematoma
❑ Lumbar puncture
❑ Brain tumor
❑ Headache in HIV
❑ Pseudotumor cerebri
❑ Hypertensive encephalopathy
❑ Carbon monoxide intoxication
❑ Giant cell arteritis
❑ Psychogenic
❑ Brain abscess
❑ Encephalitis
❑ Arteriovenous malformations
❑ Cavernous sinus thrombosis
❑ Pituitary apoplexy
❑ Carotid artery dissection
Diagnostic Approach
Red flags to serious causes include: Sudden onset of “the worst headache of my life,” especially in a non—headache-prone person; headache different from previous headaches; headache precipitated by position change, cough, or exertion; a history of trauma or fever; abnormal mental status or other neurological findings; a headache that disturbs sleep or is present immediately on awakening; immune deficiency such as HIV.
The time course helps in diagnosing headache. A “thunderclap” headache of a ruptured aneurysm peaks instantly. Cluster headache peaks over 3 to
5 minutes, remains at maximum for 45 minutes, and then gradually recedes. Migraine builds over hours, lasts hours to days, and is improved with sleep.
In evaluating patients with recurrent migraine, it is critical to ascertain whether the present headache differs from prior migraines and whether fever is present or spontaneous retinal venous pulsations are abnormally absent. These should prompt a search for alternative causes. If fever is present with headache, rule out meningitis.
Raised intracranial pressure should be suspected with blurred vision upon bending the head forward, headache upon awakening that improves with sitting up, double vision, loss of coordination and balance, or daily
progressive headache with nausea. Pain originating above the tentorium is referred to the frontal, temporal, or parietal region. Pain from the posterior fossa and below is referred to the occiput. Pain from the posterior sagittal and transverse sinuses may be referred to the eye or forehead.
Lumbar puncture, subdural hematoma, or benign intracranial hypertension can cause orthostatic headache. Occipital headache radiating to the vertex and forehead is usually a result of cervical spondylosis but can also be caused by basal subarachnoid hemorrhage, posterior fossa tumor, or meningitis.
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Source: Field Guide to Bedside Diagnosis, 2007
Headache:
Diagnosis
(Handbook of Diseases)
An accurate diagnosis requires a history of recurrent headaches and physical examination of the head and neck. Such examination includes percussion, auscultation for bruits, inspection for signs of infection, and palpation for defects, crepitus, and tender spots (especially after trauma).
A firm diagnosis also requires a complete neurologic examination, assessment for other systemic diseases (such as hypertension), and a psychosocial evaluation (when such factors are suspected).
Most patients may be diagnosed by a thorough history and physical examination. Magnetic resonance imaging, computed tomography scans, lumbar puncture, and serology may be beneficial. Neurologic deficits, such as stroke or brain tumors; metabolic processes, such as thyroid disease or diabetes; and an aneurysm must be ruled out if the headache is explosive and “the worst” in their lives.
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Source: Handbook of Diseases, 2003
Aura:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Obtain a thorough history of the patient’s headaches or seizure history, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Tension-Type Headache
Any systemic infection, usually viral orbacterial, may produce fever and headache.
Can cause vasodilatation of cerebral arteriesand produce headache. Frequent causes include high altitude, carbonmonoxide poisoning, and chronic lung disease (most commonly cysticfibrosis).
When severe, may cause headache, which canbe dull or throbbing. BP should be measured in anyone who complainsof persistent severe headache.
Systemic lupus erythematosus may cause cerebralvasculitis and headache.
Headache often occurs with various disordersinvolving head and neck region. History, physical exam, and appropriateradiographs are usually diagnostic.
Dental caries, malocclusion, and temporomandibularjoint dysfunction sometimes cause pain in frontal and temporal areasas well as jaw pain.
Pain-sensitive intracranial structures includecerebral and dural arteries and large cerebral veins and venoussinuses. Traction on these structures produces headache.
Obtain a thorough history of the patient's headache or seizure history, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.
Then perform a complete neurologic examination.
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Does he have a history of high blood pressure? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Does he experience stress at work or at home? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the past 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or vision changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures or does he have a history of seizures?
Begin the physical examination by evaluating the patient's level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—a widened pulse pressure, bradycardia, an altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness.
Good communication between a doctor and patient is crucial. Migraine sufferers should prepare to discuss details of their symptoms with their...