Headache is a topic covered in the Harrison's Manual of Medicine.

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Approach to the patient

Among the most common reasons that pts seek medical attention; can be either primary or secondary (Table 49-1). First step—distinguish serious from benign etiologies. Symptoms that raise suspicion for a serious cause are listed in Table 49-2. 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 HeadacheSecondary Headache
Tension-type69Systemic infection63
Migraine16Head injury4
Idiopathic stabbing2Vascular disorders1
Exertional1Subarachnoid hemorrhage<1
Cluster0.1Brain tumor0.1
Source: After J Olesen 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 years
Fever or unexplained systemic signs
Abnormal neurologic examination
Pain associated with local tenderness, e.g., region of temporal artery

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TY - ELEC T1 - Headache ID - 623187 Y1 - 2017 PB - Harrison's Manual of Medicine UR - https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623187/all/Headache ER -