Headache

From IKE

Contents 1 History 2 Physical 3 Differential 4 Common headaches 5 Treatment

History

• Age at onset
• Presence or absence of aura and prodrome
• Frequency, intensity and duration of attack
• Number of headache days per month
• Time and mode of onset
• Quality, site, and radiation of pain
• Associated symptoms and abnormalities
• Family history of migraine
• Precipitating and relieving factors
• Effect of activity on pain
• Relationship with food/alcohol
• Response to any previous treatment
• Any recent change in vision
• Association with recent trauma
• Any recent changes in sleep, exercise, weight, or diet
• State of general health
• Change in work or lifestyle (disability)
• Change in method of birth control (women)
• Possible association with environmental factors
• Effects of menstrual cycle and exogenous hormones (women)

Physical

• BP HR
• TEMP
• Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation
• Palpate the head, neck, and shoulder regions
• Check temporal and neck arteries
• Examine the spine and neck muscles
• A functional neurologic examination including getting up from a seated position without any support, walking on tiptoes and heels, cranial nerve examination, fundoscopy and otoscopy, tandem gait and Romberg test, and symmetry on motor, sensory, reflex and cerebellar (coordination) tests.

• Warning signs:
  • Neck stiffness and especially meningismus (resistance to passive neck flexion) suggests meningitis.
  • Papilledema suggests the presence of an intracranial mass lesion, benign intracranial hypertension (pseudotumor cerebri), encephalitis, or meningitis.
  • Focal neurologic signs suggest an intracranial mass lesion, arteriovenous malformation, or collagen vascular disease.
  • Headache worse with valsalva or position change suggestive of tumour

Differential

• Potentially fatal:
  • Subarachnoid hemorrhage
  • Tumor (esp. metastatic)
  • ruptured AVM
  • Meningitis
  • Encephalitis
  • subdural hematoma
  • Carotid dissection
  • Optic neuritis (esp with sudden, severe monocular blindness)
  • Pheochromocytoma

• Other:
  • Migraine headache
  • Tension headache
  • Cluster headache (0.1%)
  • Sinus headache
  • Medication-associated headache
  • Fever
  • Acute hypertension
  • posttraumatic
  • Giant cell arteritis (esp. in >50)
  • Secondary to refractive error (rare)
  • TMJ

Headache with fever:

• Intracranial infection
  • Meningitis
    • Bacterial
    • Fungal
    • Viral
    • Lymphocytic
  • Encephalitis
  • Brain abscess
  • Subdural empyema

• Systemic infection
  • Bacterial infection
  • Viral infection
  • HIV/AIDS
  • Other systemic infection

• Other causes
  • Familial hemiplegic migraine
  • Pituitary apoplexy
  • Rhinosinusitis
  • Subarachnoid hemorrhage

Common headaches

Symptom	Migraine headache	Tension headache	Cluster headache
Location	Unilateral in 60 to 70 percent; bifrontal or global in 30 percent	Bilateral	Always unilateral, usually begins around the eye or temple
Characteristics	Gradual in onset, crescendo pattern; pulsating; moderate or severe intensity; aggravated by routine physical activity	Pressure or tightness which waxes and wanes	Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality
Patient appearance	Patient prefers to rest in a dark, quiet room	Patient may remain active or may need to rest	Patient remains active
Duration	4 to 72 hours	Variable	30 minutes to 3 hours
Associated symptoms	Nausea, vomiting, photophobia, phonophobia; may have aura (usually visual, but can involve other senses or cause speech or motor deficits)	None	Ipsilateral lacrimation and redness of the eye; stuffy nose; rhinorrhea; pallor; sweating; Horner's syndrome; focal neurologic symptoms rare; sensitivity to alcohol

Treatment

• NSAIDs
• Acetaminophen
• Triptans
• Ergots
• DHE
• antiemetic

• See [1]