Diagnosis of 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

BLURRED VISION, BLINDNESS, AND SCOTOMATA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A careful eye examination with magnification and fluorescence to rule out a foreign body and ulcers is essential in the acute case of blurred vision. Ophthalmoscopic examination may reveal optic neuritis or a retinal vein thrombosis. Visual field examination by confrontation may reveal a field defect. If these test results are negative, ocular tension should be checked to rule out glaucoma. A history of migraine, the use of birth control, and alcohol intake must be investigated. If there is headache on the side of the lesion, a sedimentation rate is done, steroids should probably be started immediately, and referral to a neurologist made promptly in case temporal arteritis is possible, especially in the aged. Otherwise, referral to an ophthalmologist is necessary. The ophthalmologist will perform visual field examinations with perimetry, a slit lamp examination, and look for refractive errors. If other neurologic findings are present, a CT scan, skull x-ray film, and spinal tap may be indicated. A neurologic consultant can determine this.

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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

West Nile encephalitis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

The immunoglobulin (Ig) M antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) is the test of choice for rapid definitive diagnosis. The major advantage of MAC-ELISA laboratory analysis is the high probability of accurate diagnosis of WNV infection when performed with acute serum or cerebrospinal fluid specimens obtained while the patient is still hospitalized.

A new diagnostic test, the WNV MAC-ELISA, was recently approved by the Food and Drug Administration. This test detects levels of IgM antibodies in a patient's ser-um and is intended for use in patients with clinical symptoms consistent with viral encephalitis.

Other conditions to consider include St. Louis encephalitis, which is symptomatically similar.

Encephalitis can be caused by numerous viral and bacterial infections; all data must be examined to determine a definitive diagnosis.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Cutaneous larva migrans: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Characteristic migratory lesions strongly suggest cutaneous larva migrans. A thorough patient history usually reveals contact with warm, moist soil within the past several months.

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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

Night blindness [Nyctalopia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient complains of difficulty seeing at night, ask when he first noticed the problem. Is it intermittent or steadily worsening? Is it worse at certain times or in certain conditions? Also, ask about other ocular symptoms, such as eye pain, blurred or halo vision, floaters or spots, and photophobia.

Explore any history of glaucoma, cataracts, and familial degeneration of vision. If no ocular problems are apparent, briefly evaluate the patient’s nutritional status for vitamin A deficiency.

Examine the eyes for ptosis, abnormal tearing, discharge, and conjunctival injection. Test visual acuity and visual fields in both eyes and, if trained and equipped, measure intraocular pressure. Check pupillary response, and evaluate extraocular muscle function by testing the six cardinal fields of gaze.

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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

Encephalitis: Diagnosis
(Handbook of Diseases)

During an encephalitis epidemic, diagnosis is easily based on clinical findings and patient history. Sporadic cases are difficult to distinguish from other febrile illnesses, such as gastroenteritis and meningitis. When possible, identification of the virus in cerebrospinal fluid (CSF) or blood confirms the diagnosis.

The common viruses that also cause herpes, measles, and mumps are easier to identify than arboviruses. Arboviruses and herpesviruses can be isolated by inoculating young mice with specimens taken from patients. In herpes encephalitis, serologic studies may show rising titers of complement-fixing antibodies. Virus-specific indirect fluorescent antibody assays have improved diagnosis.

In all forms of encephalitis, CSF pressure is elevated, and despite inflammation, the fluid is clear in many cases. White blood cell and protein levels in CSF are slightly elevated, but the glucose level remains normal. An EEG reveals abnormalities. Occasionally, a computed tomography scan may be ordered to rule out cerebral hematoma.

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Source: Handbook of Diseases, 2003

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

West Nile encephalitis: Diagnosis
(Handbook of Diseases)

The immunoglobulin M antibody capture–enzyme-linked immunosorbent assay is the test of choice for rapid definitive diagnosis. It has a high probability of accurate diagnosis of WNV infection when performed with acute serum or cerebrospinal fluid specimens obtained while the patient is hospitalized.

Encephalitis can also be caused by numerous viral and bacterial infections, so data must be carefully examined to determine a definitive diagnosis. St. Louis encephalitis, which is symptomatically similar to West Nile encephalitis, should be considered.

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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?

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Night blindness: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient complains of difficulty seeing at night, ask when he first noticed the problem. Is it intermittent or steadily worsening? Is it worse at certain times or in certain conditions? Also, ask about other ocular symptoms, such as eye pain, blurred or halo vision, floaters or spots, and photophobia.

Explore any history of glaucoma, cataracts, and familial degeneration of vision. If no ocular problems are apparent, briefly evaluate the patient’s nutritional status for vitamin A deficiency.

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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