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Number 1 A Method To Simplify The Diagnosis Of Headache Based on Three Simple Questions , The proper evaluation of the patient with headache includes a careful history and thorough physical examination, the latter emphasizing the neurological examination. After completing these steps, the busy practitioner might then think of multiple possible diagnoses, often in a haphazard order. In order to formulate a more rational differential diagnosis, the answers to three questions are required. 1) How long has the patient been having headaches? 2) How often do the headaches occur? 3) How long does each individual headache last? Using the answers to these questions, headaches can be divided into the following five groups, each of which contains a list of the most likely causes in that group. The causes are listed in order of their approximate frequency of occurrence in the population as a whole – not in frequency of patients seeking care. Group I Headaches With Explosive Onset 1) 2) 3) 4) Acute post-traumatic headache Thunderclap headache Subarachnoid hemorrhage Stroke Acute trauma to the head or neck is frequently followed by headache. Most often the patient recognizes the cause and may or may not seek medical care. Acute post-traumatic headaches start within one week following the injury and cease by the twelfth week. If they continue longer than twelve weeks, the diagnosis is chronic post-traumatic headache (see group V below). The other conditions on this list are true medical emergencies and require neuroimaging studies and often a lumbar puncture. Group II 1) 2) 3) 4) Recent Onset Headaches with Progressive Course Rhinitis/ sinusitis – allergic or bacterial Systemic infectious illness Meningoencephalitis –viral, bacterial, spirochetal, fungal, tubercular Adverse event from a medication 1 5) 6) 7) 8) 9) Abnormal intracranial pressure Headache caused by caffeine withdrawal Cervicogenic headache Hypothyroidism Hypertension – (if systolic >190 or diastolic >120) This group includes headaches beginning hours, days or even weeks earlier. Most are major medical conditions requiring specific therapy. The history and examination usually reveal other symptoms and/ or signs that point to the diagnosis. If proper therapy is administered, many of the conditions in this group can be corrected. Allergic rhinitis/ sinusitis is accompanied by pressure over the sinuses, nasal congestion and discharge that is often non-purulent. There may be a history of similar attacks in previous years. A careful history may reveal additional symptoms which point to the diagnosis of migraine. Both conditions might respond to simple analgesics. This is in contrast to the purulent drainage, fever and often unilateral frontal headache with bacterial sinusitis, a condition that is less frequent. The headaches with systemic infections may start before the patient develops significant fever, cough or other symptoms. Headache may be the only symptom of meningoencephalitis and neck stiffness may be absent or minimal. Occasionally cryptococcal meningitis might be present for several months before cells and protein elevation appear in the spinal fluid. The Physicians Desk Reference mentions headache as an adverse event of almost every medication. The onset of headache may occur weeks or even months after a daily medication is started. When confronted with a patient having headache, the physician should stop every medication that is not essential. If the patient is on an essential medication, it should be changed to another medication having the same action. An example would be to change a beta-blocker being given for hypertension to a calcium channel blocker. Headaches presenting as an adverse event from medications generally clear rapidly if the offending medication is discontinued. There are various causes of altered intracranial fluid pressure. Benign intracranial hypertension (also called idiopathic intracranial hypertension and pseudotumor cerebri) is not uncommon. The patient is often female, obese and may have various visual abnormalities. Only 8% of adult brain tumors present with headache in the absence of seizures or other abnormal neurological symptoms and signs. Low spinal fluid pressure typically presents with postural headache, neck pain and dizziness. The headache worsens as the patient stands and improves after lying down. With low CSF pressure a contrast MRI may shows marked meningeal enhancement. 2 Caffeine withdrawal headaches occur on those days when the person does not consume their daily caffeine which is usually taken with breakfast. Patients often have neck problems that are not the cause of their headaches. For example they might have chronic arthritic problems in the neck but infrequent headache. The physician must always ask which started first and inquire about the temporal relationship of the headaches and neck conditions. The diagnosis of cervicogenic headache is often made in error. Hypothyroidism is usually diagnosed from the other symptoms typical for that condition. Mild elevations of blood pressure are usually asymptomatic. The classic British study showed that hypertension rarely caused headache at levels below 190 systolic and 120 diastolic. Group III Recurrent Headaches with Irregular Frequency 1) 2) 3) 4) 5) Ice cream headache Episodic tension-type headache Episodic Migraine Benign idiopathic stabbing headache Stimulus induced headaches positional, exertional, cough, coital Although ice cream headaches occur almost universally, the patients with this condition almost never seek medical attention. Most patients with infrequent or episodic tension-type headaches obtain relief with simple OTS (off the shelf) medications and never seek medical attention. Chronic tension-type headache (occurring >15 days/ month) is included in group V below. From this list, the patient with migraine is the most likely to seek medical attention. Primary, essential or episodic migraine occurs in patients who are headache-free on most days of the month. This is in contrast to the person having frequent migraine (greater than 15 days per month) or some days with migraine and a dull, tensiontype headache on most of the other days. The latter two conditions are having chronic daily headache (see group V below). Group IV Recurrent Daily or Almost Daily Paroxysmal Headaches (Lasting Less Than 4 Hours) 1) 2) 3) 4) Cluster headache Paroxysmal hemicrania Headache due to sleep apnea Hypnic headache 3 The main features distinguishing cluster headache from paroxysmal hemicrania is the severity, frequency and duration of each headache. Cluster headaches are excruciating, rarely occur more than four times a day and the pain lasts for 30-180 minutes. The headaches of paroxysmal hemicrania are less intense, may occur as often as eight times a day and the individual headaches last less than 30 minutes. Headaches due to sleep apnea are noted upon awakening in the mornings and usually resolve within 30 minutes. Hypnic headache usually occur in the elderly and are only nocturnal, often awakening the patient at the same time each night. . Group V Recurrent Daily or Almost Daily Continuous or Almost Continuous Headache (Lasting longer than 4 hours) 1) Rebound headache (medication overuse headache) 2) Adverse event from medications 3) Chronic post-traumatic headache (most often a form of rebound headache) 4) Depression 5) Chronic tension-type headache (rarely is a presentation of rebound) 6) Hemicrania continua (can be a presentation of rebound) This last group of headaches includes the patients causing the most diagnostic and therapeutic difficulty for the physician. These patients repeatedly seek medical care, additional imaging studies and additional medications to terminate or prevent their headaches. In the medical literature and in the latest classification of headaches by the International Headache Society (IHS), there has been an unfortunate lack of uniformity in defining the conditions listed in this table of chronic daily headaches (CDH). Some authors have advocated separate diagnoses for daily headaches with gradual onset and a history of prior migraine (transformed migraine), new onset with or without medication overuse, only unilateral pain, etc. The terms used in this list have been chosen because they are simple to comprehend and are in widespread use. The majority of these patients with CDH are experiencing rebound headache – a term that emphasizes that the medications taken for today’s headache rebound and are causing tomorrow’s headache. The IHS classification designates these as medication overuse headaches. Often the patient had started the pain medication for some other condition such as postoperative pain, trauma, fever or joint problems. Rebound headaches can result from the overuse of any acute pain medication, even the triptans. These daily headaches might have started when the patient was using daily or almost daily pain medications, but continue to be daily or almost daily after the patient changes to another pain medication or reduces their medications to only one or two days a week. After these patients stop all pain relief medications, their recovery is slow – at times requiring 6+ months to reach the goal of once a week or less frequent headache. Studies 4 have shown that over 75% of the patients who follow the advice to completely stop the pain medications can reach that goal. Daily headache as an adverse event from a medication can continue for months or even years if the offending medication is not stopped. The condition was discussed earlier under group II. Acute post-traumatic headaches are common but last less than twelve weeks. Chronic post-traumatic headaches are rebound headaches until proven otherwise. Symptoms of depression are frequent in patients with rebound headache, but usually begin after the headaches have started. A patient with pre-existing chronic depression might note an increase in the severity of their depression if they later develop rebound headache. Infrequently a patient might present with a short history of depression – three months or so – followed by daily tension-type headache. In the latter patient both problems might respond to a low dose of a simple tricyclic antidepressant. Daily or almost daily tension-type headache without any migraine component is an unusual presentation of rebound headache and infrequently responds to analgesic termination. Many chronic tension-type headaches fail to improve with any pharmacological approach. Chronic hemicrania continua, especially if the unilateral headaches are a combination of unilateral tension-type and unilateral migraine, is rebound until proven otherwise. The patient should stop all analgesics. If the patient is having mild to moderate constant, unilateral, steady pain that is associated with autonomic findings and intermittent exacerbations, they are probably having true hemicrania continua and should initially be treated with Indomethacin. Revised February 6,2012 5