49 Questions
What is the definition of a headache, or cephalalgia, according to the text?
Diffuse pain in various parts of the head, not confined to the area of distribution of a nerve
What percentage of young women experienced headache during a 12-month period according to the text?
95 percent
What are the two categories into which headaches are divided for evaluation and management?
Primary and secondary
What is the estimated annual cost associated with missed workdays and medical benefits due to headaches in the American industry?
$50 billion
What is the typical age range for the onset of most primary headache disorders?
Childhood or between 20 and 50 years of age
When does the onset of headache after 50 years of age raise concern for secondary headache disorders?
Temporal arteritis or mass lesions
What is necessary for careful evaluation of new-onset headache in adults?
Neuroimaging and/or cerebrospinal fluid (CSF) analysis
What may the sudden onset of headache indicate?
Subarachnoid hemorrhage, pituitary apoplexy, or hemorrhage into a mass lesion or vascular malformation
What requires thorough evaluation in a patient with new-onset headache?
Risk factors for HIV infection or cancer metastasis
What may focal neurologic signs or symptoms of systemic illness indicate?
A serious condition
Why is it crucial to determine whether the current episode of headache is typical if the patient routinely experiences headaches?
To identify potential life-threatening secondary disorders
How can symptoms experienced before and during the headache help in the evaluation?
Identify primary headache disorders or potentially life-threatening secondary disorders
Why are questions about the time and nature of headache onset essential?
In identifying secondary headache disorders
What is important in distinguishing between different types of headaches?
Determining the location and radiation of pain
What should be considered in patients over 50 with acute headache and elevated ESR?
Temporal arteritis
When is CSF analysis needed for patients with acute headache?
When they have red flags and normal neuroimaging
What percentage of patients had CT scans ordered in the evaluation of headaches?
3%
What were the main reasons for ordering CT scans in the evaluation of headaches?
Suspected tumor (49%) or subarachnoid hemorrhage (9%)
What led to 17% of CT scans in the evaluation of headaches?
Patient expectations and medicolegal concerns
What is preferred to rule out subarachnoid hemorrhage within the first 48 hours?
Lumbar puncture
What is more sensitive than CT in identifying intracranial changes?
MRI
When should neuroimaging be considered in patients?
With unexplained abnormal findings on neurologic exam
What factors should be considered when ordering CT or MRI for evaluation of headaches?
Need to identify acute hemorrhage and posterior fossa evaluation
What percentage of CT scans were ordered due to suspected tumor in the evaluation of headaches?
49%
What should be considered in patients with unexplained abnormal findings on neurologic exam?
Neuroimaging
Which type of headache is strictly unilateral?
Cluster headache
What can trigger drug-rebound and nonspecific headaches?
Caffeine-containing analgesics
Which condition makes patients more likely to have an organic cause of their headaches?
HIV
What type of headache can trauma, such as head injuries, trigger?
Migraine
What is essential to identify causes of secondary headaches?
Physical examination
What should prompt additional evaluation in the context of headaches?
Papilledema
What should be investigated further for secondary headache disorders?
Unilateral loss of sensation
What type of headache is usually bilateral and band-like?
Tension-type headache
What can be indicative of specific underlying conditions, such as temporal arteritis?
The type of pain described by the patient
What is limited laboratory testing performed for when temporal arteritis is a possibility?
Complete blood count
What is essential to diagnose migraine without aura and migraine with aura?
Characteristics such as duration, pain intensity, and associated symptoms
What may be performed when systemic or intracranial infection is suspected?
Complete blood count
What is the preferred imaging modality to rule out hemorrhage in the evaluation of acute headaches?
Noncontrast CT scan
When abnormal findings are observed during a neurologic examination, what is warranted to rule out intracranial pathology?
CT scan
In the evaluation of acute headaches, what can help to confirm or rule out hemorrhage, infection, tumor, and disorders related to CSF hypertension or hypotension?
Cerebrospinal fluid (CSF) analysis
For which type of imaging is MRI necessary, but it is more expensive and less widely available than CT scanning in the evaluation of acute headaches?
MRI
What is the appropriate course of action for patients with headaches that are difficult to diagnose, worsen, or fail to respond to management?
Refer for further evaluation
Which type of headache disorders are usually recurrent without organic disease as their cause?
Migraine, tension-type, and cluster headaches
What is crucial to determining the etiology of a headache in the evaluation of acute headaches?
Detailed headache history
What can a thorough headache history facilitate in the evaluation of acute headaches?
Generation of a differential diagnosis
What question is essential to identify red flags that suggest an underlying organic disorder as the cause of headache?
Is this your first or worst headache?
What is the preferred imaging modality to rule out subarachnoid hemorrhage within the first 48 hours?
Noncontrast CT scan
What are primary headache disorders usually recurrent with, without organic disease as their cause?
Migraine, tension-type, and cluster headaches
What is necessary for careful evaluation of new-onset headache in adults?
Thorough neurologic examination
Study Notes
Diagnosis and Management of Headaches
- Different types of headaches can be indicative of specific underlying conditions, such as temporal arteritis, trigeminal neuralgia, or acute glaucoma.
- The quality of the pain described by the patient can help classify the headache as migraine, tension-type, or cluster headaches.
- Patients with concurrent medical conditions like HIV, cancer, or hypertension are more likely to have an organic cause of their headaches, such as CNS lymphoma or intracranial vascular disorders.
- Medications, including over-the-counter ones and caffeine-containing analgesics, can trigger drug-rebound and nonspecific headaches.
- Trauma, such as head injuries or medical procedures like lumbar puncture, can trigger migraines and cluster headaches.
- Diagnostic criteria for migraine without aura and migraine with aura are based on characteristics such as duration, pain intensity, and associated symptoms like nausea and photophobia.
- Cluster headaches are strictly unilateral, while tension-type headaches are usually bilateral and band-like.
- The physical examination is essential to identify causes of secondary headaches, targeting areas identified as abnormal during the headache history.
- Red flags for serious problems, such as focal neurologic findings and papilledema, should prompt additional evaluation.
- Specific findings, including unilateral loss of sensation and hyperreflexia, should prompt further investigation for secondary headache disorders.
- Limited laboratory testing, such as a complete blood count or erythrocyte sedimentation rate, may be performed when systemic or intracranial infection is suspected or when temporal arteritis is a possibility.
- Historical and physical findings considered red flags offer the best means of identifying a secondary headache disorder, prompting additional evaluation.
Evaluation of Acute Headaches in Adults
- "Red flags" for secondary disorders include sudden onset of headache, onset after 50 years of age, increased frequency or severity, new onset with underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema, and headache subsequent to head trauma.
- A thorough neurologic examination should be performed, with abnormal findings warranting neuroimaging to rule out intracranial pathology.
- Noncontrast CT scan is the preferred imaging modality to rule out hemorrhage, followed by lumbar puncture if the CT scan is normal.
- MRI reveals more detail and is necessary for imaging the posterior fossa, but it is more expensive and less widely available than CT scanning.
- Cerebrospinal fluid (CSF) analysis can help to confirm or rule out hemorrhage, infection, tumor, and disorders related to CSF hypertension or hypotension.
- Referral is appropriate for patients with headaches that are difficult to diagnose, worsen, or fail to respond to management.
- Primary headache disorders include migraine, tension-type, and cluster headaches and are usually recurrent without organic disease as their cause.
- Acute secondary headache disorders can be associated with head trauma, vascular disorders, nonvascular intracranial disorders, substance use or withdrawal, noncephalic infection, and metabolic disorders.
- A thorough headache history is crucial to determining the etiology of a headache, as most patients with headache have normal neurologic and general physical examinations.
- A detailed headache history facilitates the generation of a differential diagnosis and preliminary classification of the headache type based on the criteria established by the International Headache Society.
- The question “Is this your first or worst headache?" is essential to identify red flags that suggest an underlying organic disorder as the cause of headache.
- This article is part of a series coordinated by the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., with guest editors Francis G. O’Connor, LTC, MC, USA, and Jeannette E. South-Paul, COL, MC, USA.
"Diagnosis and Management of Headaches" quiz covers the evaluation and classification of different types of headaches, including migraine, tension-type, and cluster headaches. It delves into the red flags for secondary disorders, appropriate imaging modalities, and the importance of a thorough headache history and physical examination. This quiz is essential for healthcare professionals seeking to enhance their knowledge and skills in diagnosing and managing acute headaches in adults.
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