Approach To Headaches

Headache is one of the most common complaints of patients in the western world. It periodically afflicts 90% of adults, and almost 25% have recurrent severe headaches. As with many common symptoms, a broad range of conditions, from trivial to life-threatening, might be responsible. The majority of patients presenting with headache have tension-type, migraine, or cluster: however, fewer than one in 20 have significant underlying pathology. Because headache symptoms usually are accompanied by a paucity of associated findings, including those on laboratory examination, the clinician must depend largely upon a thorough history with a general and focused neurologic examination as the initial workup. Careful inquiry and meticulous physical examination, keeping in mind the "red Hags" of headaches (Table 50-1), will serve the clinician well. Differentiating serious underlying causes of headache from more benign causes may be difficult. Table 50-2 lists some typical features of serious causes of headache.

One of the most catastrophic secondary causes of headache is subarachnoid hemorrhage, usually secondary to a ruptured intracerebral (berry) aneurysm. Up to 4% of patients presenting to an emergency center with severe headache, or the classic "worst ever headache," have a subarachnoid bleed. The initial hemorrhage may be fatal, may result in severe neurologic impairment, or may produce only minor symptoms such as headache. A high index of suspicion is needed because no neurologic findings may be present initially, and the patient who will benefit the most from intervention will often have the mildest symptoms. The first diagnostic study should be a noncontrast CT scan with thin imaging cuts at the region of the brain base. This study will be positive in more than 90% of cases on the first day, with decreasing sensitivity over the next several days. If hemorrhage is suspected but the CT is negative, lumbar puncture should be performed as soon as possible to assess for the

Table 50-2

The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

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