HEADACHE

HEADACHE: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the Following Questions:

1. Is there a history of drug, caffeine, or alcohol ingestion? The hangover headache is well known and should not present a problem in diagnosis. Caffeine withdrawal headaches are also common because of the large amount of caffeine consumed in coffee, various soft drinks, and chocolate. Drugs that may induce headache include the nonsteroidal anti-inflammatory drugs such as indomethacin (Indocin®) and the anti-hypertensives such as clonidine, aspirin, quinidine, and bromides.
2. Is there a history of trauma? Trauma may cause concussion and postconcussion headaches, intracranial neoplasms such as subdural hematoma, and cervical sprain, all of which can induce headaches.
3. Is the headache acute or chronic? An acute onset of a headache can be a serious problem. It should be taken seriously because it may mean a subarachnoid hemorrhage or meningitis. This can be easily confirmed by checking for nuchal rigidity. Whenever there is an acute onset of a headache this must be done. Chronic headaches, on the other hand, are most likely due either to migraine if they occur in exacerbations or remissions, or to tension headaches if they are fairly constant, mild, and chronic. The headache of a brain tumor is rarely severe and is rarely the presenting symptom of a brain tumor. Headaches that occur in clusters almost daily for 6 to 8 weeks with interruptions of several months must make one consider cluster headaches. Unilateral headaches in the elderly with acute onset should make one think of temporal arteritis.
4. Is there nuchal rigidity? The presence of nuchal rigidity should make one think of a subarachnoid hemorrhage or meningitis, but it may also be due to cerebral hemorrhage or cerebral abscess.
5. Is there fever? If the headache is associated with fever, the possibility of acute sinusitis should be considered, and the sinuses should be transilluminated. Other sources for the fever should be looked for, and meningitis or encephalitis should be considered.
6. Is there papilledema or are there focal neurologic signs? With acute headache and focal neurologic signs and/or papilledema, one should consider cerebral abscess or cerebral hemorrhage. With a chronic headache and papilledema or focal neurologic signs, one should consider a space-occupying lesion such as a primary brain tumor or metastatic neoplasm.
7. Do the sinuses transilluminate well? A sinus transilluminator should be in the armamentarium of every physician who expects to diagnose headache. If the sinuses fail to transilluminate, one should consider acute sinusitis as the diagnosis.
8. Is there tenderness of the superficial temporal artery? The presence of a tender superficial temporal artery should make one think of temporal arteritis, particularly in the elderly, but it may also be related to a long-standing migraine attack.
9. Is the headache relieved by superficial temporal artery compression? Relief of the headache on superficial temporal artery compression should suggest classical or common migraine. If one can relieve the headache by compression of the occipital artery, occipital migraine should be considered. When there is no relief on compression of the superficial temporal artery, one should consider tension headaches, occipital neuralgia, cervical spondylosis, and cluster headaches as the cause.

DIAGNOSTIC WORKUP

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.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 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: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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