HEADACHE

28 HEADACHE

General Discussion

The majority of patients with headache experience either migraine, tension-type, or medication rebound headaches. Serious or anatomical causes of headaches are uncommon but have to be considered when a patient presents with a headache. Headaches, and migraines in particular, occur more frequently in women and can be very disabling.

Migraine headaches are usually unilateral, throbbing, and worsen with exercise and typically last 4–72 hours. They are often associated with nausea, vomiting, and sensitivity to light and sound. Associated auras are usually visual or sensory disturbances. Most severe, recurrent headaches are migraines.

Tension headaches, on the other hand, are usually mild and frequently can be treated with over-the-counter pain medications. Unlike migraines, they are usually bilateral and not affected by physical activity. They are often described as a pressure, ache, tightness, or “band-like constriction” around the head. Location of symptoms is commonly cervical, occipital, or temporal, though numerous variants exist. Nausea with or without vomiting may be associated with tension headaches.

Medication rebound headache should be high on the differential diagnosis for any patient with chronic daily headaches. A patient may begin with migraine or tension-type headache on an episodic basis, but then transform to medication rebound headache with the frequent use of analgesics. Medication rebound headache may be caused by either over-the-counter or prescription medications. Combination medications such as Excedrin (caffeine, aspirin, and acetaminophen) are often implicated.

Less common types of headaches include trigeminal neuralgia and idiopathic intracranial hypertension (also known as pseudotumor cerebri or benign intracranial hypertension). Trigeminal neuralgia occurs in the distribution of the trigeminal nerve, lasts only seconds to minutes, and feels like electric shocks. Headaches caused by trigeminal neuralgia can be triggered by touching the affected area. Idiopathic intracranial hypertension (IIH) is associated with papilledema and visual changes and can lead to blindness. Young obese women are at particular risk for IIH.

When evaluating a patient with a headache it is essential to rule out a serious cause of headache by assessing any red flags during the history and physical. These red flags include neurologic symptoms or signs, older age at onset, systemic illness or symptoms (such as fever, cancer, pregnancy or postpartum status, use of anticoagulants), sudden onset, new headache, different or progressive headache, headache awakening the patient from sleep, and occipital headache. Headaches that can have severe consequences if they remain undiagnosed include subarachnoid hemorrhage (sudden onset) and other intracranial bleeds, IIH, meningitis (associated with fever, neck rigidity) and other infections, brain neoplasm (may be associated with seizures), and giant cell arteritis (associated with temporal artery tenderness, diminished temporal artery pulse, jaw claudication, polymyalgia rheumatica, and visual changes).

Potential indicators of intracranial pathology in patients with sudden-onset acute headache are occiptonuchal location, age greater than 40 years, and an abnormal neurologic examination. Symptoms of particular concern in patients with non-acute headache include increasing frequency or progressive symptoms, neurologic signs or symptoms, or headache awakening the patient from sleep (not explained by cluster headache or typical migraine).

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Aug 17, 2016 | Posted by admin in PEDIATRICS | Comments Off

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