Headache

Headache is one of the most common primary care complaints. It may be an isolated or recurrent event; it may be idiopathic or secondary to an underlying structural lesion; or it may simply require an analgesic for pain relief or a complete and detailed workup for its source. One must distinguish benign causes of headache from malignant and life-threatening causes and treat appropriately.

Differential Diagnosis

• Tension-type headache
  –Most common cause of headache
  –Diffuse, bilateral, band-like pain
  –Lasts for hours to days
  –May occur on a fairly regular basis
• Migraine headache
  –Throbbing unilateral or bilateral pain
  –May last for days
  –May have preceding aura (flashing light)
  –Triggers include foods, drugs, or stress
• Meningitis
  –May present with fever, photophobia, neck stiffness, nausea/vomiting, papilledema
  –Brudzinski's sign: Neck pain upon passive flexion of neck
  –Kernig's sign: Neck pain and involuntary flexion upon passive extension of knee with hips flexed
• Head trauma
• Medications
• Carbon monoxide exposure
• Sinusitis
• Temporomandibular joint syndrome or dental pain
• Withdrawal from alcohol, barbiturates, caffeine, or other substance
• Temporal arteritis
  –Pain/tenderness over temporal area/jaw
  –Occurs uniquely in patients over 50
  –Blindness may occur
• Mass lesions (e.g., tumor, hematoma)
  –Daily, progressive headache
  –May awaken from sleep
  –Focal neurologic signs
• Subarachnoid hemorrhage
  –Sudden onset of “worst headache of my life”
  –Neck stiffness
  –Loss of consciousness
• Cluster headache
  –Severe, unilateral pain
  –Lasts minutes to hours
  –Occurs daily for months, then remits for months or even years
• Glaucoma
  –Retro-orbital pain
• Chronic daily headache or rebound headache (e.g., secondary to chronic analgesic use)
• Benign intracranial hypertension

Workup and Diagnosis

• History and physical exam often make the diagnosis
  –History should focus on onset, duration, frequency, possible triggers, severity, quality (e.g., throbbing, band-like), accompanying symptoms (e.g., aura, photophobia, visual changes, nausea/vomiting, lacrimation, nasal congestion), constitutional symptoms (e.g., weight loss, fever), medications, and dietary history
  –Is this first and/or worst headache of life?
  –Exam should include a complete neurologic exam, visual/retinal exam, head/neck, and gait exam

• Possible serious etiologies and need for further workup are suggested by the following red flags: Constitutional symptoms, new headache in a patient over 50, sudden onset, awakening from sleep, mental status changes, focal neurologic signs, visual/motor/balance disturbance, papilledema
• CT will identify hemorrhage and mass lesions and rule out increased intracranial pressure
• MRI will identify posterior fossa tumors
• Lumbar puncture is indicated if CT is normal but still suspect hemorrhage, infection, or tumor
• Serologies for bacterial, viral, and other causes of meningitis or encephalitis
• Elevated ESR suggests temporal arteritis or infection
• Carboxyhemoglobin measurement if history suggests carbon monoxide poisoning

Treatment

• Tension-type headache: Regular exercise, stress management, tricyclic antidepressants, analgesics
• Migraine headache: Avoid triggers; serotonin agonists (e.g., sumatriptan), NSAIDs, ergotomines
• Temporal arteritis: High-dose corticosteroids
• Meningitis: Search for and treat the primary source (e.g., pneumonia, sinusitis, neoplasm)
  –Urgent antimicrobial administration for infections
  –Treat inflammatory causes with steroids
• Subarachnoid hemorrhage requires attention to airway, breathing, and circulation, and management of increased intracranial pressure (maintain normal blood pressure; hypertension may cause the aneurysm to rebleed, hypotension may cause cerebral ischemia); administer nimodipine to prevent cerebral vasospasm, seizure prophylaxis with IV phenytoin, surgery
• Cluster headache: Oxygen inhalation for 5–10 minutes; serotonin agonists, ergotamines, and/or methysergide

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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