Headache

Headache: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ 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.

Clinical Findings

Migraine  A prodrome virtually always indicates migraine and is the sine qua non of migraine with aura (classic migraine). Neurological phenomena include visual scotoma (an expanding jagged bright border with a dark center, like a wildfire), or mood changes (usually depression or irritability). More unusually, a prodrome may consist of aphasia or hemiplegia. A unilateral headache follows, usually with vegetative symptoms of nausea, anorexia, or sensitivity to light and sound. The fundi may show arterial or venous dilation. Common migraine has no neurological prodrome although patients can often sense it coming on. Migraine can be recognized by vegetative symptoms, activators (e.g., red wine, stress, sleep or food deprivation, or strong odors) or deactivators (e.g., sleep, pregnancy, exhilaration, or sumatriptan). These headaches have their onset in adolescence or young adult age; new onset in older patients can occur but should prompt a search for structural causes.

Tension  These are experienced as pressure, a vice, or bandlike sensation around the head (vertex, frontal, or temporal). Dull and steady, they worsen as the day progresses. They may last days, weeks, or months, but
tension headaches are not relentlessly progressive. Anxiety, depression, and emotional conflicts are frequent precipitants.

Acute sinusitis  The epicenter may be frontal (frontal sinuses), over cheeks (maxillary sinuses), between the eyes (ethmoid sinuses), or in the frontotemporal and occipital region (sphenoid sinus). Headache is a continuous pressure sensation that is worsened by bending forward. Fever, nasal obstruction, and purulent nasal drainage are usually present.

Acute glaucoma  Orbital headache begins with aching around the rim and spreads through the trigeminal ophthalmic division. A tender hard globe, red eye with limbic flush, dull cornea, and impaired transmission of tangential light through the anterior chamber may be present.

Postconcussive  Contusion produces scalp tenderness at the impact site or tension-type headache. Especially after the patient’s vehicle has been rear-ended in an accident, there is headache, dizziness, vertigo, memory impairment, reduced concentration, and anxiety.

Cluster  Cluster occurs in middle-aged men as nocturnal episodes of high intensity, steady, boring, burning, unilateral orbital pain accompanied by ipsilateral red and tearing eye, nasal congestion, facial flushing, and diaphoresis. There also may be ipsilateral ptosis and miosis (20% to 40%). The headache begins a few hours after going to bed and lasts 1 to 2 hours. It recurs nightly for weeks to months and then disappears for years.

Meningitis  Fever is the key sign. The headache is severe, generalized, and constant, most intense at the base of the skull, and aggravated by forward flexion of the neck. The neck and back will be reflexively stiff to flexion (Kernig and Brudzinski sign). Nausea, photophobia, and altered mental status ranging from delirium to coma often accompany the headache. Clues regarding the cause include the following: petechial rash (meningococcus, enterovirus, S. aureus, leptospira); parotitis (coxsackie, LCM, EBV); vesicles (HSV); HIV (Listeria, pneumococcus); diabetes (pneumococcus, gram-negative, S. aureus, cryptococcus, mucormycosis); freshwater swimming (ameba); steroids (cryptococcus, mycobacteria); summer or fall onset (enterovirus, Borrelia, Leptospira). Acute otitis, sinusitis or pneumonia, basilar skull fracture, or splenectomy suggest pneumococcal meningitis. Meningococcal meningitis is suggested by fulminant onset with vascular collapse and angular purpura with a gunmetal gray color. Tuberculous meningitis is suggested by a gradual onset and multiple cranial nerve abnormalities.

Drugs  Sulfamethoxazole, ibuprofen, sulindac, ketorolac, isoniazid, azathioprine, and penicillin may cause aseptic meningitis, especially in patients with systemic lupus or mixed connective tissue disease. Concurrent facial swelling, urticaria, and conjunctivitis are helpful clues. Nitrates, ergots, amphetamines, phenothiazines, alcohol, and withdrawal from caffeine may also cause headache.

Hypoglycemia  Suspect this in a diabetic exhibiting diffuse sweating, throbbing frontal or generalized headache, weakness, confusion, and irritability.

Benign exertional headache  It occurs more commonly in patients who have migraines. Coital headache occurs abruptly with orgasm and subsides within minutes. It is usually benign, but if it lasts for hours or is accompanied by vomiting, subarachnoid hemorrhage should be considered.

Temporomandibular joint inflammation  Chewing aggravates the symptoms, and involuntary nocturnal bruxism and jaw clenching are common. Tenderness and a click over the TMJ are sensitive but not specific findings.

Subdural hematoma  Head trauma with concussion is followed by a lucid interval, then the development of mental status changes and/or focal neurological deficits such as hemiparesis, dilated pupil, and papilledema. Subdural hematoma presents with mild persistent headache, drowsiness, and confusion, and progresses to loss of consciousness.

Subarachnoid hemorrhage  Hemorrhage is sudden in onset and very severe. Headache, photophobia, nausea, meningismus, and loss of consciousness develop rapidly. A major hemorrhage has often been preceded by a similar, less severe, self-limited “herald bleed.”

Acute epidural hematoma  This is usually caused by a temporal skull fracture. A progressive decrease in the level of consciousness is the rule, although a brief lucid interval may follow recovery from a concussion before blood has accumulated.

Lumbar puncture  An intense occipitofrontal headache develops when the patient is upright and is relieved when supine. The onset may be as many as 12 days after the procedure. The original CNS indications for the lumbar puncture may make this difficult to recognize.

Brain tumor  The “classic” tumor headache that is worse in morning, accompanied by nausea and vomiting, occurs in less than 20%. It is relieved by lying down and worsened by straining at defecating, by coughing, or by bending over. Characteristically, it remains in the same location but is progressive, increasing in duration and severity over months. Being awakened at night with the headache is common but not diagnostic. Usually there are subtle neurological changes by the time the headache develops. Fundoscopy often shows increased intracranial pressure, manifest as absence of spontaneous venous pulsations to overt papilledema. Cerebral vomiting, without food, may occur. An occipital lobe tumor may be mistaken for migraine because of the production of scotoma.

Headache in HIV  Acute HIV causes aseptic meningitis accompanied by sore throat, diffuse maculopapular rash, and generalized lymphadenopathy. Cryptococcosis causes headache, fever, and nausea. Toxoplasmosis usually presents with encephalopathy or seizures. CNS lymphoma has headache or seizures. HIV encephalitis presents with seizures, memory loss, or decreased attention span.

Pseudotumor cerebri  It presents like tumor in an obese young woman, with chronic retro-orbital headache increased by eye movement. Transient blurred vision, diplopia, and vague symptoms of dizziness or facial numbness are experienced. Papilledema will often be present on examination.

Hypertensive encephalopathy  An occipital headache usually occurs with accelerated hypertension (BP .230/130), but may be seen with diastolic pressures as low as 110. The headache is worse in the morning. Hypertensive encephalopathy presents with headache, nausea, vomiting, visual disturbances, confusion, seizures, or coma. Focal neurological deficits, retinal hemorrhages, and papilledema are clues. Suspect pheochromocytoma if the headache and hypertension are paroxysmal and associated with sweating, palpitations, and weight loss.

Carbon monoxide intoxication  A prominent pounding headache develops with exposure to engine exhaust or a kerosene heater in a closed space.

Giant cell arteritis  Temporal arteritis should be considered in an elderly patient with a unilateral, dull, aching, continuous headache. It will be most intense over the temporal artery, which may be exquisitely tender and ropy or nodular. Systemic symptoms of fever and anorexia, jaw claudication (weakness, fatigue, or pain precipitated by chewing), or scalp tenderness (painful to comb the hair) often accompany the headache.

Psychogenic  Headaches are described in flamboyant terms but have no clear pattern. Terms such as lightning-like or explosive are used, but the patient experiences no visible discomfort.

Brain abscess  Parenteral drug use, lung abscess, immunodeficiency, and a parameningeal focus are clues. Fever and focal neurologic signs should be sought, but these are not universally present.

Encephalitis  Encephalitis begins acutely or subacutely with headache, fever, and signs of parenchymal involvement, such as coma, seizures, change in mental status, or focal neurological findings. Herpesvirus presents with frontal or temporal lobe neurological findings, or focal seizures, in 85%.

Arteriovenous malformations  Unilateral (always on the same side) throbbing chronic headache without aura occurs. A bruit may be heard with the stethoscope over the eye or temporal region.

Cavernous sinus thrombosis  It begins with retro-orbital headache, which is worse on sitting. Chemosis, proptosis, and painful ophthalmoplegia (deficits of cranial nerves III, IV, V) are found. Seizures or unilateral numbness or weakness may be seen. Predisposing causes include acute sinusitis, otitis, or coagulopathy.

Pituitary apoplexy  Severe bifrontal headache, drowsiness, diplopia, and visual loss (especially bitemporal hemianopia) are found.

Carotid artery dissection  Dissection occurs with neck trauma. Ipsilateral frontal, orbital, or temporal pain with Horner syndrome and focal neurological signs are clues. A carotid bruit is often found.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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