Chapter 51: Headache
Approach to the patient: 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.
PRIMARY HEADACHE | SECONDARY HEADACHE | ||
---|---|---|---|
Type | % | Type | % |
Tension-type | 69 | Systemic infection | 63 |
Migraine | 16 | Head injury | 4 |
Idiopathic stabbing | 2 | Vascular disorders | 1 |
Exertional | 1 | Subarachnoid hemorrhage | <1 |
Cluster | 0.1 | Brain tumor | 0.1 |
Source: Data from Olesen J et al: The Headaches. Philadelphia, Lippincott Williams & Wilkins, 2005.
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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Citation
Kasper, Dennis L., et al., editors. "Chapter 51: Headache." Harrison's Manual of Medicine, 20th ed., McGraw Hill Inc., 2020. harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623187/all/Chapter_51:_Headache.
Chapter 51: Headache. In: Kasper DLD, Fauci ASA, Hauser SLS, et al, eds. Harrison's Manual of Medicine. McGraw Hill Inc.; 2020. https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623187/all/Chapter_51:_Headache. Accessed November 10, 2024.
Chapter 51: Headache. (2020). In Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L., & Loscalzo, J. (Eds.), Harrison's Manual of Medicine (20th ed.). McGraw Hill Inc.. https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623187/all/Chapter_51:_Headache
Chapter 51: Headache [Internet]. In: Kasper DLD, Fauci ASA, Hauser SLS, Longo DLD, Jameson JLJ, Loscalzo JJ, editors. Harrison's Manual of Medicine. McGraw Hill Inc.; 2020. [cited 2024 November 10]. Available from: https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623187/all/Chapter_51:_Headache.
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BT - Harrison's Manual of Medicine
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