Headache
3. HEADACHE DIAGNOSIS
Benign headaches are diagnosed by identifying common patterns. Recall of headache patterns can be difficult for many patients, particularly if they have
Box 2
Evaluation of New-Onset or Worrisome Headaches
• History and physical examination
Complete review of systems
Cervical spine examination
Resting posture
Active range of motion
Palpation
Neurological evaluation
Gait
Fundoscopy for papilledema
Assess symmetry of face and eye movements
Strength and reflex testing
Sensation to touch
Able to identify two of three numbers drawn in the palm without looking
• Laboratory
Radiological testing
Computed tomography or magnetic resonance imaging (MRI) of brain
X-ray of cervical spine for mechanical abnormalities a
MRI of cervical spine for radiculopathy b
Blood work
Autoimmune tests (antinuclear antibody)
Hematology (blood count)
Sedimentation rate and temporal arteritis workup for new headache in patients aged >50 years
Chemistries (electrolytes; liver and kidney function tests)
Endocrine (thyroid function tests)
Infectious (rapid plasma reagin for syphilis)
aMechanical abnormalities include abnormal posture, restricted range of motion, or pain reproduced with neck motion.
bRadiculopathy should be considered if focal strength, reflex, or sensory loss in an arm is present.
Ask about daily prescription or over-the-counter analgesic use if daily.
4. How often do you get your headache?
5. How long does each headache episode usually last?
Headaches lasting <2 hours may be indicate cluster headaches. Also, the time course of headache may dictate therapy: short-acting medications are best for headaches that reach maximum intensity quickly; long-acting medi-cations are often needed for headaches lasting ≥12 hours.
6. What do you typically do when you have a headache?
a. Are usual activities reduced or curtailed?
b. Do you go to bed?
c. Do you need to turn off the television, radio, or lights in the room?
7. Are you having a headache right now? If so, it this how severe your headaches usually get, or is this an especially “good” or “bad” day?
Patient behavior in the clinic can be compared with historical reports if the patient is having a typical headache during the examination.
8. Where is the pain located? Is it always in the same location?
Headache pain typically shifts among different areas on the head during different headache episodes. Pain that is always located in the same spot (with the exception of cluster headache, which usually involves the same eye with each episode) or is located in the back of the head or neck often requires additional work-up.
9. Any other new problems since the headache began?
Identification of new medical or neurological symptoms will suggest the need for additional evaluations.
frequent headache or two types of headache. In this circumstance, daily head-ache diary recordings for 1 month can be a useful tool to help elucidate headhead-ache pattern and diagnosis (Fig. 5). (A sample diary is provided in Appendix E.)
Patients with frequent or daily headache often focus on their most troubling headache, neglecting to mention the additional frequent headache that is often associated with medication overuse. Diaries will also help identify if menstrua-tion is a consistent headache trigger.
Fig. 4. Headache diagnostic algorithm.
41
Fig. 5. Diary samples compared with headache diagnoses and treatment recom-mendations.
Fig. 5. (Continued from previous page.)
Contrasting features of different headache patterns help distinguish most com-mon, chronically recurring headaches (Fig. 6). Migraine headaches are intermit-tent and result in patients needing to curtail work activities. Although migraine is disabling, it usually occurs infrequently, usually once or twice monthly. Some patients have frequent migraine, at most typically twice weekly. Migraine is not a daily headache. Each episode of migraine typically lasts approximately 6 to 12 hours. Tension-type headache, by contrast, is more frequent and long lasting, with milder episodes often lasting all day. Cluster headache is a very short-last-ing, high intensity headache that often occurs at night, approximately 90 minutes after initiating sleep, when dream sleep occurs. Pain is typically unilateral orbital
Fig. 6. Pattern of common recurring headaches. Some patients will have a combi-nation of migraine and tension-type patterns, experiencing both patterns simulta-neously. Posttraumatic headache may resemble migraine or tension-type headache.
Medication overuse headache has a daily headache pattern similar to that for tension-type headache. Cluster headaches are characteristically very brief and very intense, and tend to recur predictably during a cluster period.
or periorbital. Although cluster headache is generally associated with autonomic features, like pupillary changes or discharge from the eye and nostril, few cluster headache patients will note these features in their history, possibly because of the extreme intensity of the head pain. By contrast, migraineurs often endorse eye tearing and nasal discharge, although these features are very mild in comparison to their occurrence with cluster headache. Therefore, using the presence of auto-nomic features to distinguish migraine from cluster headache is often counter-productive.
Medication overuse or rebound headache can be difficult to diagnosis unless a high index of suspicion is maintained. Medication overuse will not cause head-ache in a headhead-ache-free patient; however, the headhead-ache pattern of the chronic headache sufferer will be aggravated by medication overuse. Typically, patients experience a change from intermittent migraine to a daily tension-type headache.
Another common scenario is the perpetuation of posttraumatic headache, with frequent headaches persisting longer than expected. Every patient reporting fre-quent headache should be repeatedly queried about medication overuse and required to complete a headache diary to log both headache and medication use.
Any acute care medication (triptans, ergotamine, analgesic or analgesic combi-nations, opioids, and butalbital combinations) may contribute to medication over-use headache. Patients with benign headache taking any acute care medication or combination of acute care medications on a regular basis at least 3 days per week for at least 6 weeks should be diagnosed with probable medication overuse
head-ache. Switching among different acute care agents on different days does not minimize risk of medication overuse headache. Patients should have at least 5 days per week during which they use no acute care medication.
Posttraumatic headaches occur within 2 weeks of a head injury. The head injury should be significant enough to have produced a concussion, which may be experienced as “feeling dazed,” “seeing stars,” having amnesia for events before or after the accident, or a brief loss of consciousness. Postcon-cussive syndrome features often accompany posttraumatic headaches: depressed or irritable mood, memory loss, dizziness or vertigo, and tinnitus. Posttraumatic headache should improve from constant and severe to milder and less frequent over the first 2 weeks. Headaches failing to improve, worsening, or associated with progressive postconcussive symptoms should be reevaluated with imag-ing studies to rule out subacute pathology, such as subdural hematoma or undi-agnosed fracture. Headache features are often consistent with migraine in the early phases of posttraumatic headache, and become milder like tension-type headache when posttraumatic headache persists.