What if you have a headache?
The anamnesis and the results of an objective examination in most cases allow to presume a diagnosis and determine the further tactics of the patient's examination.
Headache should be characterized by such parameters, which are important for the diagnosis, include the age of onset of headaches; frequency, duration, localization and intensity; factors that provoke, aggravate or alleviate pain; concomitant symptoms and diseases (eg, fever, neck stiffness, nausea, vomiting, mental changes, photophobia), as well as previous illnesses and events (eg head trauma, cancer, immunosuppression).
An episodic, relapsing, intense headache, starting in adolescence or early adulthood, is most likely primary. Unbearable (lightning-fast) pain in the head can indicate a subarachnoid hemorrhage. Daily subacute and progressive headache may be a symptom of volume formation. Headache, beginning after age 50 and accompanied by soreness in palpation of the scalp, pain in the mandibular joint during chewing and decreased vision, is most likely due to temporal arteritis.
Confusion, convulsive seizures, fever, or focal neurological symptoms indicate a serious cause that requires further examination.
The presence of concomitant pathology in an anamnesis can explain the cause of headaches: for example, recent head trauma, hemophilia, alcoholism or treatment with anticoagulants can cause subdural hematoma.
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It is necessary to perform a neurological examination, including ophthalmoscopy, assessment of mental status and checking meningeal symptoms. Recurrent episodic headache in patients who, at first glance, look healthy and do not have neurological abnormalities, is rarely caused by a serious cause.
Rigidity of the neck muscles during flexion (but not during rotation) indicates irritation of the brain membranes due to infection or subarachnoid hemorrhage; increased body temperature indicates infection, but a slight increase in temperature may accompany hemorrhage. Painfulness in the palpation of the vessels of the temporal region in most cases (> 50%) indicates a temporal arteritis. Edema of the optic discs indicates increased intracranial pressure, which may be due to malignant hypertension, neoplasm, or thrombosis of the sagittal sinus. Morphological changes (eg, tumors, strokes, abscess, hematoma) are usually accompanied by focal neurological symptoms or changes in mental status.
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Imaging methods and laboratory tests are necessary only in cases when the history or the results of the survey cause suspicion of the presence of pathology.
Patients who need urgent CT or MRI to detect hemorrhage and other morphological changes that cause headaches include those with: conditions such as
- suddenly developed headache;
- change in mental status, including convulsive seizures;
- focal neurological symptoms;
- edema of the optic disc;
- severe arterial hypertension.
Due to the fact that conventional CT can not completely exclude conditions such as subarachnoid hemorrhage, meningitis, encephalitis or inflammatory processes, a lumbar puncture is indicated for suspected cases.
Immediate, but not urgent, CT or MRI is required if the headache changes its habitual character, the first headache after 50 years, the presence of systemic symptoms (such as weight loss), the presence of secondary risk factors (such as cancer, HIV, trauma head) or chronic unexplained headaches. For these patients, MRI with gadolinium and magnetic resonance angiography or venography is preferred; MRI allows you to visualize a number of important potential causes of headaches that are inaccessible to CT (for example, carotid artery stenosis, cerebral venous thrombosis, pituitary apoplexy, vascular malformations, cerebral vasculitis, Arnold Chiari syndrome).
Intensive persistent headache is an indication for lumbar puncture to exclude chronic meningitis (eg, infectious, granulomatous, tumor).
Other diagnostic methods are used according to complaints and clinical picture to confirm or exclude specific causes (eg, determination of ESR for the exclusion of temporal arteritis, measurement of intraocular pressure in case of suspected glaucoma, dental x-rays if suspected tooth pulp abscess).