Headache

History

  • Onset and frequency
  • Location
  • Precipitating factors
  • Type of pain
  • Associated s/sx – n/v (migraine, increased ICP), photo/phonophobia (migraine), fever (meningitis, dental abscess), unilateral lacrimation/rhinorrhea (cluster HA), LOC changes (tumor, SAH)

Physical exam

  • HEENT (trauma)
  • Structural causes – sinus tenderness, tooth tenderness, TMJ
  • If fever, check for meningeal irritation
  • CN exam
  • Papilledema with pseudotumor/increased ICP

Differential - classic presentation

Primary
Tension headache Bilateral, dull bandlike pain > 30 min, constant
Cluster headache Unilateral, repetitive headaches 15 min – 3 hrs, excruciating stabbing periorbital pain a/w autonomic sx (lacrimation, rhinorrhea)
Migraine Unilateral, pulsating pain lasting hrs, a/w nausea, photo/phonophobia, aura
Trigeminal neuralgia In middle-aged/elderly patients, lancinating pain in V2/V3, triggered by tactile stimulation/movement
Secondary
Sinusitis  
TMJ disorder  
Pseudotumor cerebri  0-40 yo F, obese, a/w b/l visual sx (blurry vision, papilledema)
Intracranial neoplasm  
Temporal (giant cell) arteritis > 50 yo. headache over temporal arteries a/w scalp tenderness, jaw claudication
Meningitis  
Subarachnoid hemorrhage  
   
  • CBC
  • ESR (elevated to > 100 in temporal arteritis)
  • LP – blood in CSF with SAH; elevated pressure > 250 mmH2O in pseudotumor cerebri
  • CT/MRI – normal in pseudotumor

Tension

NSAIDs/acetaminophen

Cluster

O2, sumatriptan

Migraine

Preventive – propranolol, verapamil, amitriptyline, topiramate

Abortive – Sumatriptan, NSAIDs

-        Triptans contra-indicated in uncontrolled HTN/CAD due to vasoconstrictive effects

SAH

 

Temporal arteritis

Temporal artery biopsy (multiple), do not delay onset of prednisone x 1-2 yrs

Trigeminal neuralgia

Carbamazepine, surgical decompression. Rule out MS/tumors in younger patients with MRI

Pseudotumor cerebri

Acetazolamide to dec CSF formation. Visual sx with optic nerve sheath fenestration

Post-LP headache

Self-resolving, caffeine, blood patch (inject patient’s blood into epidural space at LP site to clot)

 

 
author: admin | last edited: Sept. 22, 2017, 8:53 p.m. | pk: 66 | unpublished