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Approach to the Patient With Headache
Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical attention.
Headache may occur as a primary disorder or be secondary to another disorder. Primary headache disorders include migraine, cluster headache (including chronic paroxysmal hemicrania and hemicrania continua), and tension-type headache. Secondary headache has numerous causes (see Table: Disorders Causing Secondary Headache).
Overall, the most common causes of headache are
Some causes of headache are common; others are important to recognize because they are dangerous, require specific treatment, or both (see Table: Some Characteristics of Headache Disorders by Cause).
Disorders Causing Secondary Headache
Some Characteristics of Headache Disorders by Cause
Evaluation focuses on determining whether a secondary headache is present and checking for symptoms that suggest a serious cause. If no cause or serious symptoms are identified, evaluation focuses on diagnosing primary headache disorders.
History of present illness includes questions about headache location, duration, severity, onset (eg, sudden, gradual), and quality (eg, throbbing, constant, intermittent, pressure-like). Exacerbating and remitting factors (eg, head position, time of day, sleep, light, sounds, physical activity, odors, chewing) are noted. If the patient has had previous or recurrent headaches, the previous diagnosis (if any) needs to be identified, and whether the current headache is similar or different needs to be determined. For recurrent headaches, age at onset, frequency of episodes, temporal pattern (including any relationship to phase of menstrual cycle), and response to treatments (including OTC treatments) are noted.
Review of systems should seek symptoms suggesting a cause, including
Vomiting: Migraine or increased intracranial pressure
Fever: Infection (eg, encephalitis, meningitis, sinusitis)
Red eye and/or visual symptoms (halos, blurring): Acute angle-closure glaucoma
Visual field deficits, diplopia, or blurring vision: Ocular migraine, brain mass lesion, or idiopathic intracranial hypertension
Lacrimation and facial flushing: Cluster headache
Pulsatile tinnitus: Idiopathic intracranial hypertension
Preceding aura: Migraine
Focal neurologic deficit: Encephalitis, meningitis, intracerebral hemorrhage, subdural hematoma, tumor, or other mass lesion
Seizures: Encephalitis, tumor, or other mass lesion
Syncope at headache onset: Subarachnoid hemorrhage
Myalgias and/or vision changes (in people > 55 yr): Giant cell arteritis
Past medical history should identify risk factors for headache, including exposure to drugs, substances (particularly caffeine), and toxins (see Table: Disorders Causing Secondary Headache); recent lumbar puncture; immunosuppressive disorders or IV drug use (risk of infection); hypertension (risk of brain hemorrhage); cancer (risk of brain metastases); and dementia, trauma, coagulopathy, or use of anticoagulants or ethanol (risk of subdural hematoma).
Family and social history should include any family history of headaches, particularly because migraine headache may be undiagnosed in family members.
To streamline data collection, clinicians can ask patients to fill out an online headache questionnaire that covers most of the relevant medical history pertinent to diagnosis of headache; it is available at ProMyHealth . Patients may complete the questionnaire before their visit and bring the results with them.
Vital signs, including temperature, are measured. General appearance (eg, whether restless or calm in a dark room) is noted. A general examination, with a focus on the head and neck, and a full neurologic examination are done.
The scalp is examined for areas of swelling and tenderness. The ipsilateral temporal artery is palpated, and both temporomandibular joints are palpated for tenderness and crepitance while the patient opens and closes the jaw.
The eyes and periorbital area are inspected for lacrimation, flushing, and conjunctival injection. Pupillary size and light responses, extraocular movements, and visual fields are assessed. The fundi are checked for spontaneous venous pulsations and papilledema. If patients have vision-related symptoms or eye abnormalities, visual acuity is measured. If the conjunctiva is red, the anterior chamber and cornea are examined with a slit lamp if possible, and intraocular pressure is measured.
The nares are inspected for purulence. The oropharynx is inspected for swellings, and the teeth are percussed for tenderness.
Neck is flexed to detect discomfort, stiffness, or both, indicating meningismus. The cervical spine is palpated for tenderness.
The following findings are of particular concern:
Neurologic symptoms or signs (eg, altered mental status, weakness, diplopia, papilledema, focal neurologic deficits)
Immunosuppression or cancer
Onset of headache after age 50
Thunderclap headache (severe headache that peaks within a few seconds)
Symptoms of giant cell arteritis (eg, visual disturbances, jaw claudication, fever, weight loss, temporal artery tenderness, proximal myalgias)
Systemic symptoms (eg, fever, weight loss)
Progressively worsening headache
Red eye and halos around lights
If similar headaches recur in patients who appear well and have a normal examination, the cause is rarely ominous. Headaches that have recurred since childhood or young adulthood suggest a primary headache disorder. If headache type or pattern clearly changes in patients with a known primary headache disorder, secondary headache should be considered.
Most single symptoms of primary headache disorders other than aura are nonspecific. A combination of symptoms and signs is more characteristic (see Table: Some Characteristics of Headache Disorders by Cause).
Red flag findings suggest a cause (see Table: Matching Red Flag Findings with a Cause for Headache).
Matching Red Flag Findings with a Cause for Headache
Most patients can be diagnosed without testing. However, some serious disorders may require urgent or immediate testing. Some patients require tests as soon as possible. CT (or MRI) should be done in patients with any of the following findings:
In addition, if meningitis, subarachnoid hemorrhage, or encephalitis is being considered, lumbar puncture see Lumbar puncture (spinal tap) and CSF analysis should be done, if not contraindicated by imaging results.
Tonometry should be done if findings suggest acute narrow-angle glaucoma (eg, visual halos, nausea, corneal edema, shallow anterior chamber).
Other testing should be done within hours or days, depending on the acuity and seriousness of findings and suspected causes.
Neuroimaging, usually MRI, should be done if patients have any of the following:
ESR should be done if patients have visual symptoms, jaw or tongue claudication, temporal artery signs, or other findings suggesting giant cell arteritis.
CT of the paranasal sinuses is done to rule out complicated sinusitis if patients have a moderately severe systemic illness (eg, high fever, dehydration, prostration, tachycardia) and findings suggesting sinusitis (eg, frontal, positional headache, epistaxis, purulent rhinorrhea).
Lumbar puncture and CSF analysis are done if headache is progressive and findings suggest idiopathic intracranial hypertension (eg, transient obscuration of vision, diplopia, pulsatile intracranial tinnitus) or chronic meningitis (eg, persistent low-grade fever, cranial neuropathies, cognitive impairment, lethargy, vomiting, focal neurologic deficits).
Recurrent headaches that began at a young age in patients with a normal examination are usually benign.
Immediate neuroimaging is recommended for patients with altered mental status, seizures, papilledema, focal neurologic deficits, or thunderclap headache.
CSF analysis is required for patients with meningismus and usually, after neuroimaging, for immunosuppressed patients.
Patients with thunderclap headache require CSF analysis even if CT and examination findings are normal.
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