Headache
A. H&P
Similarity to previous HAs, onset and time course, N/V, photophobia, neck pain, trauma, fever, neurological aura, change in sx with position, h/o cancer, family history of aneurysms or migraine, what drugs work for pain. Cranial or sinus tenderness, eye changes, focal neurological signs.
B. Causes
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1. Sudden paroxysmal headache (HA): Intracranial hemorrhage (especially subarachnoid), arterial dissection, benign orgasmic HA, thunderclap migraine, hypertensive crisis….
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2. Subacute progressive HA: Posterior fossa stroke, cerebral vein thrombosis, temporal arteritis, tumor, obstructive hydrocephalus, CSF leak (e.g., post LP), meningitis, sinusitis, or other infection, vascular malformations, glaucoma….
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3. Recurrent or chronic HA: Migraine, neck arthritis, postconcussive syndrome, pseudotumor cerebri, neuralgia, temporal arteritis, temporomandibular syndrome, drugs (stimulants, solvents, alcohol withdrawal)….
C. Tests
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1. Sudden or subacute headache (HA): CT without contrast to r/o bleed, or with contrast to r/o tumor.
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a. Consider also: MRA to r/o vascular malformations, dissections, aneurysm. LP to r/o SAH, meningitis, or leptomeningeal carcinomatosis.
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2. Recurrent or chronic HA: Can usually be diagnosed without tests. Consider ESR.
D. Cluster HA
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1. H&P: Occur at the same time each day, nonthrobbing, uniorbital, ipsilateral running nose, red eye, red cheek, tender temporal artery, lasts 10 min to 2 h, up to 8 times a day, sometimes with Horner’s. Alcohol can trigger. Unlike migraneurs, cluster headache sufferers do not lie still, but may walk restlessly. Youngish men.
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