Headache
Headache: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Robert B. Taylor
Headache is one of the 20 most frequent reasons patients visit primary care providers in the United States. Migraine headache, one of the common causes of recurrent headache, occurred one or more times yearly in 17.6% of females and in 5.7% of males in a study of 20,468 persons (1).
Approach.
In the evaluation of a recurrent headache, the important tasks are to categorize the headache type with as much precision as possible and to eliminate potentially serious causes.
A. Headache types. Basically, two types of recurrent headache are seen: primary headaches and headaches caused by other illnesses (Table 2.5).
B. Special concerns include a brain tumor, intracranial bleed, meningitis, or other serious causes. In primary care patients with “headache” as a presenting symptom, the risk of serious intracranial pathology is less than 1% (2). Generally, such patients have a history of a new onset or worsening headache pattern or an abnormal neurologic finding, which might include a seizure (Chapter 4.7).
History
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).
Testing
A. Clinical laboratory tests. For most recurrent headache patients, no blood, urine, or other clinical laboratory tests are needed. Laboratory tests that might be suggested by the clinical history and PE include erythrocyte sedimentation rate (temporal arteritis), hematocrit or thyroid studies (fatigue), cerebrospinal fluid examination (meningeal irritation), and white blood count with differential (systemic infection).
B. Diagnostic imaging. In most instances, diagnostic imaging is not needed. In one study, 350 patients with a chief complaint of headache, regardless of the presence or absence of neurologic signs, were referred for computed tomography (CT). Only 2% had clinically significant CT findings, and all patients with significant CT findings had abnormal PE findings or unusual clinical symptoms (3).
1. Diagnostic imaging may be indicated in patients with atypical headache patterns, a history of seizures, or focal neurologic signs or symptoms (4). New onset and “worst ever” headaches are significant complaints (i.e., atypical headache patterns).
2. Despite the greater cost, magnetic resonance imaging (MRI) provides the best imaging for the detection of brain tumors and most other chronic pathologic causes of headache that can be detected by imaging. CT is preferred if acute bleeding is suspected.
V. Diagnostic assessment. The key to the diagnosis of headache is the clinical history. A history of an aching, bitemporal headache that is associated with stress and that waxes and wanes is a typical tension headache. Migraine is characteristically a one-sided headache, throbbing in nature, often associated with nausea and vomiting, frequently accompanied by photophobia and sonophobia, and lasting 4 to 12 hours, perhaps longer. It may be “with aura” (classic) or “without aura” (common migraine), with the latter seen in 70% to 80% of migraineurs. Cluster headache is a strictly one-sided, recurring headache that chiefly affects men, and that occurs in “clusters” of 1 to 2 months of episodes. An increasing number of patients have chronic daily headache, often with virtual constant discomfort; many CDHs are the result of “transformed migraine” following daily analgesic use, especially codeine derivatives (5). Because recurrent headache is caused, at least in part, by life stresses and because it also causes personal and family stress, the diagnostic assessment is incomplete until this complex relationship has been adequately explored over a series of visits.
References
1. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. JAMA 1992;267:64–69.
2. Becker L, Iverson DC, Reed FM, et al. Patients with new headache in primary care: a report from ASPN. J Fam Pract 1988;27:41–47.
3. Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache 1993;33:83–86.
4. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations: summary statement. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1994;44:
1353–1354.
5. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near daily headaches: field trials of revised IHS criteria. Neurology 1997;49:638–639.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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