Headache

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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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).

Types of Headache

Cluster headache

Coital headache

Exercise-induced headache

Medication rebound headache

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