Headache

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Chapter 16 HEADACHE

The majority of patients with headache experience migraine, tension-type, or medication rebound headaches. Serious or anatomic causes of headaches are uncommon but have to be considered when a patient presents with a severe headache. Headaches, particularly migraines, occur more frequently in women and can be disabling.

Migraine headaches are usually unilateral and throbbing, worsen with exercise, and typically last 4 to 72 hours. They are often accompanied by nausea, vomiting, and sensitivity to light and sound. Associated auras are usually visual or sensory disturbances. Most severe, recurrent headaches are migraines.

Tension headaches, in contrast, are usually mild and frequently can be treated with over-the-counter pain medications. Unlike migraines, they are usually bilateral and not affected by physical activity. They are often described as a pressure, ache, tightness, or “bandlike constriction” sensation around the head. Location of symptoms is commonly cervical, occipital, or temporal, although numerous variants exist. Nausea with or without vomiting may be associated with tension headaches.

Medication rebound headache should be part of the differential diagnosis for any patient with chronic daily headaches. A patient’s condition may begin as migraine or tension-type headache on an episodic basis and then transform to medication rebound headache with the frequent use of analgesics. Medication rebound headache may be caused by either over-the-counter or prescription medications. Combination medications such as caffeine, aspirin, and acetaminophen (Excedrin) are often implicated.

Other types of headaches that are more common in women include trigeminal neuralgia and idiopathic intracranial hypertension (IIH) (also known as pseudotumor cerebri or benign intracranial hypertension). Trigeminal neuralgia occurs in the distribution of the trigeminal nerve, lasts only seconds to minutes, and feels like electric shocks. Headaches caused by trigeminal neuralgia can be triggered by touching the affected area. IIH is associated with papilledema and visual changes and can lead to blindness. Young obese women are at particular risk for IIH.

In evaluating a patient with a headache, it is essential to rule out a serious cause of headache by assessing any ominous findings in the history and physical examination. These findings include neurologic symptoms or signs, older age at onset, systemic illness or symptoms (such as fever, cancer, pregnancy or postpartum status, and use of anticoagulants), sudden onset of headache, new type of headache, different or progressive headache, headache that awakens the patient from sleep, and occipital headache. Headaches that can have severe consequences if they remain undiagnosed include those associated with subarachnoid hemorrhage (sudden onset) and other intracranial bleeds, IIH, meningitis (associated with fever and neck rigidity) and other infections, brain neoplasm (which may be associated with seizures), and giant cell arteritis (associated with temporal artery tenderness, diminished temporal artery pulse, jaw claudication, polymyalgia rheumatica, and visual changes).

Potential indicators of intracranial disease in patients with sudden-onset acute headache are occipitonuchal location, age of more than 40 years, and abnormal findings of neurologic examination. Symptoms of particular concern in patients with nonacute headache include increasing frequency or progressive symptoms, neurologic signs or symptoms, or pain that awakens the patient from sleep (not explained by cluster headache or typical migraine).

Key Historical Features

✓ Location of headache

✓ Nature of headache

✓ Pattern of headache

✓ Duration of headache

✓ Frequency of headache

✓ Severity of headache

✓ Age when headaches first experienced

✓ Triggers (exercise, food, sex, coughing, cold liquids)

✓ Associated symptoms

• Nausea or vomiting

• Vision changes

• Nasal congestion

• Facial pain

• Jaw claudication

✓ Recent lumbar puncture/epidural injection

✓ Recent trauma

✓ Medical history, especially that of the following:

• Prior headaches

• Lung disease

• HIV infection

• Thyroid disease

• Hypertension

• Preeclampsia

• Heart disease

✓ Surgical history

✓ Obstetric history

✓ Social history

• Tobacco, alcohol, drugs, caffeine use

• Diet and physical activity

• Domestic violence

✓ Family history, especially of headaches

✓ Medications, including anticoagulants and pain medications

✓ Neurologic symptoms

• Change in mental status

• Memory loss

• Personality changes

• Balance problems

• Speech difficulty

• Loss of consciousness

✓ Psychologic symptoms

• Sleep history and whether headaches awaken patient from sleep

• History or symptoms of depression, anxiety, or personality disorders

✓ Gynecologic/obstetric symptoms

• Relation of headache to menstrual cycle

• Date of most recent menstrual period

✓ Gastrointestinal symptoms

• Right upper quadrant abdominal pain, which may be associated with preeclampsia

Key Physical Findings

✓ Vital signs, especially hypertension or fever

✓ Body mass index

✓ General assessment of well-being and mental status

✓ Head and neck examination for evidence of ear infection; sinusitis; TMJ syndrome; neck stiffness; neck tenderness; or temporal artery tenderness, swelling, or erythema

✓ Funduscopic examination to evaluate for papilledema

✓ Neurologic examination (complete)

✓ Musculoskeletal examination for any muscle tenderness or trigger points

Suggested Work-Up

In the absence of neurologic findings, episodic migraine does not necessitate imaging studies. The evidence is less clear for chronic headache, whether migraine or nonmigraine.

The American Academy of Neurology states that neuroimaging should be considered in patients with unexplained abnormal findings on the neurologic examination, but it also states that there is no clear evidence to recommend magnetic resonance imaging (MRI) or computed tomographic (CT) scanning as the initial examination.

Patients who have had a stable headache pattern for at least 6 months rarely have significant intracranial disease. In the absence of worrisome features, these patients do not require imaging.

Features that raise the index of suspicion for a pathologic cause in patients with chronic or recurrent headaches include systemic symptoms or illness (especially fever, change in mentation, use of anticoagulation, current or recent pregnancy, or cancer), neurologic symptoms or signs (papilledema, asymmetric cranial nerve or motor function, or abnormal cerebellar function), recent or sudden onset of headache, onset after 40 years of age, or history of a different type of headache or progression of severity of headaches.

If there are features that raise the index of suspicion for a pathologic cause, as mentioned previously, brain MRI or brain CT scanning should be performed.

Additional Work-Up

Complete blood cell count	If infection or anemia is suspected
HIV test	If the patient is at risk for HIV infection
Lumbar puncture	If meningitis or subarachnoid hemorrhage is suspected
Blood culture	If meningitis is suspected
Measurement of erythrocyte sedimentation rate	If giant cell arteritis is suspected
Temporal artery biopsy	If giant cell arteritis is suspected
Thyroid-stimulating hormone (TSH)	If thyroid disease is suspected
Urine pregnancy test	If pregnancy is suspected
Urinalysis	To evaluate for proteinuria in a pregnant patient
Liver function tests and measurement of creatinine, uric acid, and lactate dehydrogenase	If preeclampsia is suspected
Measurement of prothrombin time, partial prothrombin time, and international normalized ratio (INR)	If preeclampsia or hemorrhage is suspected or a patient is taking an anticoagulant
Sinus radiography or CT scanning	If sinusitis is suspected

FURTHER READING

Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med. 2003;3:S550-S555.

Frishberg BM. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations. Neurology. 1994;44:1191-1197.

Johnson CJ. Headache in women. Prim Care. 2004;31:417-428.

Levin M. The many causes of headache: migraine, vascular, drug-induced, and more. Postgrad Medicine. 2002;112(6):67-68. 71-72, 75-76

Maizels M. The patient with daily headaches. Am Fam Physician. 2004;70:2299-2306.

Marcus DA. Focus on primary care: diagnosis and management of headache in women. Obstet Gynecol Surv. 1999;54:395-402.

Paulson GW. Headaches in women, including women who are pregnant. Am J Obstet Gynecol. 1995;173:1734-1741.

Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754-762.

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