| | HEADACHE
Doorway information about patient
the patient is a 40-year-old woman who comes to the clinic due t headaches.
Vital signs
. Temperature : 37’C
. Blood pressure ; 120/70 mmHg
. Pulse: 80/min
. Respiratory rate; 19/min
Approach to the patient
Most primary headache syndrome(eg, migraine, tension-type headache) usually present at a young age, and often become less severe with age . Onset 9 or significant change) at age> 40 justified greater concern. clinical features suggesting a potentially serious causes of headache are summarized by the mnemonic “SNOOP”
. -Systemic- symptoms ( eg, weight loss, fever) or disease (eg, cancer , HIV/AIDS)
. -Neurologic symptoms (eg, cal deficits , altered sensorium)
. Sudden -onset-
. -Older- age at first occurrence
. Change from previous headache
headache are usually diagnosed based on historical features . Examination is normal in most patients , and is primarily focused on ruling out uncommon diagnosis.
Differential diagnosis
Types of headaches
Migraine
Sex predilection - Female> male
Family history - often present
Onset - variable
location - Often unilateral
Character - pulsatile & throbbing
Duration - 4-72 hours
Associated symptoms - Auras , photophobia, photophobia & nausea
Cluster
Male>Female
No
During sleep
Behind eye
Excruciating , sharp &steady
15-90 minutes
sweating , facial flushing , nasal congestion m lacrimation &pupillary changes
Tension
Female> male
No
under stress
Band-like pattern around the head(bilateral)
Dull , tight &persistent
30 minutes to 7 days
Muscle tenderness in the head , neck , or , shoulders
Tension -type headache is the most common headache syndrome. It begins slowly over several hours and may act for days if not treated . Characteristic feature include a bilateral squeezing or pressure sensation , particularly at the temporal or occipital area . Associated symptoms (eg, nausea , visual changes ) are rare.
Sure migraine headaches are usually unilateral , have throbbing quality , and may e associated with nausea and visual disturbances .Migraines generally have a rapid onset and recognizable triggers such as caffeine , food/beverages (eg, chocolate, red wine) , or menstruation . migraines can be categorized as -without aura-(common migraine) or -with aura-(classic migraine) . An -Aura- is a transient neurologic (usually visual) symptom at the beginning of the headache . A history of “flashing lights” or “ wavy lines ‘ in the visual fields flooded by a throbbing unilateral headaches is virtually pathognomonic for migraine . Atypical migraines are common , and many nonstandard headache types(eg , sings headache ) actually represent migraine variants.
Secondary headaches are less common than primary headache syndromes but usually more ominous . major syndromes include:
. Intracranial neoplasm: Morning or nocturnal headaches , worsened by bending over , neurologic deficits, or seizure .
. Subarachnoid hemorrhage : Severe and sudden onset(“worst headache of mil life”) , vomiting , loss of consciousness, neck stiffness
. Angel closure glaucoma: Periorbital pain , vomiting , visual symptoms, abnormal ocular examination
. Bacterial meningitis: Fever, confusion , nuchal rigidity
. Giant cell arteritis : Age > 50 , temporal location , jaw claudication , shoulder or hip pain.
. Hypertensive encephalopathy: Rapid rise in blood pressure (>180/120 mmHg)
HISTORY AND PHYSICAL EXAMINATION
In addition to the standard general medical history and physical examination , the following sections include the most common items that could be include in the evaluation of headaches.
History
history of present illness
. Describe what your headaches feel like.
. How long have you had these headaches?
. Do they start gradually or suddenly?
. Are they constant or intermittent?
. How severe are they (scale1-10)?
. Where do you feel the headaches?
. Dose it hurt anywhere else(eg, jaw, neck)?
. What were you doing when the headaches started?
. Dose anything relieve the pain ? Make it worse?
. Is there nay relation to foods or your menstrual cycle?
. Do you have nausea or vomiting ?
. Have you had headaches like this before?
. Do you have ay working signs (eg, blurry vision, light flashes)before the headache starts?
. Do you have nay fever or chills?
. Have you had any weakness , tingling , or numbers in your arms or legs?
Past medical history
. Do you have a history of cancer?
. Have you been tested for HIV?
Family history
. Is there anyone in your family with severe headaches?
Physical examination
HEENT
. Examine fundi(hypertensive changes , papilledema)
. Palpate scalp( temporal artery tenderness)
. Examine years & tympanic membrane
. Examine nose & throat
Neck
. Auscultate ofr carotid bruits
. Palpate for goiter or lymphadenopathy
Musculoskeletal
. Palpate muscles in neck & shoulders for tenderness
. Assess cervical range of motion
Neurologic
. Assess level of consciousness
. Examine cranial nerves
. Evaluate motor & sensory function in arms & legs
. Romberg test
. Check for cerebellar signs
. Assess gait
Closing the encounter
Older patients or patients with atypical symptoms amy need additional diagnostic testing . in such cases , explain the possible causes and the goals of the tests. Give the patient an accurate assessment of the diagnostic uncertainly (eg “ Your symptoms suggest benign migraines , but it its usual for someone your age to have headaches for the first time. I would like to do additional testing to be sure .”) Explain that there are no tests to confirm migraine or tension-type headaches, but tests are done to rule out other disorders.
Diagnostic studies
Young patients with a classic headache history may to need any diagnostic tests . If no tests are needed to confirm the diagnosis , write , “ No studies indicated “ in the Diagnostic Studies section.
Patients with focal neurogenic symptoms ( other than a stereotypical aura) or any off the “ SNOOP” criteria should be considered for -neuroimaging- . Patient with suspected -subarachnoid hemorrhage- or signs of elevated intracranial pressure usually undergo an urgent -CT scan- . For less urgent indications , MRI has greater sensitivity.
-Lumbar puncture(LP) - may be considered in the evaluation of atypical or potentially serious headache syndrome . LP can confirm subarachnoid hemorrhage , but CT is done first . Otters indications for LP include-bacterial meningitis - and idiopathic intracranial hypertension (pseudo tumor cerebri)
Patients with possible -giant cell arteritis- should have -erythrocyte sedimentation rate or C-reactive protein- tests . Patients with fever or otters systemic symptoms should have a -complete blood count- . Patient with severe hypertension should have an -ECG- and -renal function studies- (blood urea nitrogen , creatinine , urinalysis).
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2018/05/24 09:55pm 
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