Most Headache Etiologies are Determined via HISTORY
90% of the headaches among adults are migraine, tension type and cluster (far less common – approx 1%)
GREAT RESOURCE: International Headache Society
Pocket Version of International Classification of Headache Disorders – diagnostic criteria for all headache disorders, including neuralgia, migraine variants, etc.
• Acute Vs Chronic? “Have you ever had a headache like this before?” “How long have you been having these headaches?” → helps guide Ddx
Temporal qualities: Speed of onset, duration, time to max intensity,
Frequency: Best to Quantify “Headache Days per month”
Location: Unilateral (if so, always on same side?), retro-orbital
Triggers/alleviating factors: Trauma, position change (worse w/ supine?) sleep disruptions, stress, posture, neck pain
Assoc sx: Phono- or photophobia, aura, N/V, vertigo, eye pain or visual changes, other neuro sx, fevers, myalgias
Medications: Including OTC analgesics (rebound), opioids, nitrates, caffeine, tobacco, EtOH, assess compliance with Anti-Hypertensives, prior HA therapies
Other: PMHx (immunosuppression), FamHx of HA
• Exam: VS (fever, HTN): Neuro exam w/ emphasis on CNs including fundoscopic exam, visual fields, EOM
Exam of turbinates/sinus tenderness, can also assess tympanic membranes
Eval Neck circumference, Muscle tension in back/neck. Assess for meningismus
Appropriate Labs? Lab work is typically not useful in determining diagnosis, but becomes relevant if there is concern for secondary headache (see if there is uncontrolled BP, symptoms of hyper/hypothyroid, features of inflammatory or auto-immune disease)
HOW ARE WE GOING TO HELP THESE PATIENTS?
• IMAGING?: Remember SNOOP
●Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised)
●Neurologic symptoms or abnormal signs (eg, confusion, decreased LOC, papilledema, focal neurologic signs/sx, meningismus, or seizures)
●Onset is new (particularly for age >40 years) or sudden (eg, “thunderclap”)
●Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity)
●Previous headache history with significant headache progression or change in attack frequency, severity, or clinical features without apparent cause
Patient is a 76 year old female who presents as a same-day sick visit (last regular visit was three months ago, without any significant findings)
She complains of a headache that started when she got up from her dining room table to put her dish in the sink. She had to grab on to the kitchen counter to keep from passing out. She notes the intensity to be 10 out of 10 and appears acutely uncomfortable in the room. She does not recall having a headache of this severity before, though she does have occasional headaches that are relieved by Tylenol.
Previous Visit: Presents for ongoing eval of her well controlled Afib on Rivaroxaban for stroke risk reduction (Risk due to Age, HTN). BP 122/67 HR 74. She had received her flu vaccine and was going for a DEXA scan due to history of Osteopenia. Meds refilled.
Physical exam today: BP 155/90 HR 60. Patient does appear diaphoretic and has mild neck stiffness – can look down but notes pain on doing so. She also notes that the text on her intake form was difficult to read for her, due to blurring.