Chapter 51: Headache

Approach to the patient: Headache

Among the most common reasons that pts seek medical attention; can be either primary or secondary (Table 51-1). First step—distinguish serious from benign etiologies. Symptoms that raise suspicion for a serious cause are listed in Table 51-2. Intensity of head pain rarely has diagnostic value; most pts who present with worst headache of their lives have migraine. Headache location can suggest involvement of local structures (temporal pain in giant cell arteritis, facial pain in sinusitis). Ruptured aneurysm (instant onset), cluster headache (peak over 3–5 min), and migraine (pain increases over minutes to hours) differ in time to peak intensity. Provocation by environmental factors suggests a benign cause.

Complete neurologic examination is important in evaluation of headache. If examination is abnormal or if serious underlying cause is suspected, an imaging study (CT or MRI) is indicated as a first step. Lumbar puncture (LP) is required when meningitis (stiff neck, fever) or subarachnoid hemorrhage (following negative imaging) is a possibility. The psychological state of the pt should also be evaluated because a relationship exists between pain and depression.

TABLE 51-1: Common Causes of Headache
Tension-type69Systemic infection63
Migraine16Head injury4
Idiopathic stabbing2Vascular disorders1
Exertional1Subarachnoid hemorrhage<1
Cluster0.1Brain tumor0.1
Source: Data from Olesen J et al: The Headaches. Philadelphia, Lippincott Williams & Wilkins, 2005.
TABLE 51-2: Headache Symptoms That Suggest a Serious Underlying Disorder
Sudden-onset headache
First severe headache
“Worst” headache ever
Vomiting that precedes headache
Subacute worsening over days or weeks
Pain induced by bending, lifting, cough
Pain that disturbs sleep or presents immediately upon awakening
Known systemic illness
Onset after age 55
Fever or unexplained systemic signs
Abnormal neurologic examination
Pain associated with local tenderness, e.g., region of temporal artery

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