This document provides an overview of the approach to evaluating patients presenting with headache. It begins by noting that headache is one of the most common reasons patients seek medical attention. It then discusses the structures in the head involved in headache pain. The document outlines criteria for differentiating between primary and secondary headaches. It provides guidance on evaluating acute headaches, including symptoms that suggest a serious underlying disorder requiring further workup. The document concludes by reviewing diagnostic criteria for migraine and discussing some examples of secondary headaches like meningitis, intracranial hemorrhage, and glaucoma.

1. Shumayla Aslam, MD
2nd Year
Approach to patients with
Headache
EMILIO AGUINALDO COLLEGE MEDICAL CENTER- CAVITE
DEPARTMENT OF INTERNAL MEDICINE
YEAR 2018

2. Approach to patients with
headache
Source: Harrison’s 20th edition pg 85-89;
uptodate: evaluation of patients with headache

3. Headache
• Most common reason patients Seek medical attention
• Responsible for more disability than any other
neurologic problem
• The vast majority of patients presenting with severe
headache have a benign cause.
• Pain producing cranial structures are
• Scalp
• Meningeal arteries
• Dural sinuses
• Falx cerebri
• Proximal segments of large pial arteries

5. HEADACHE
* International Headache Society
PRIMARY SECONDARY

6. • Primary structures involved
• The large intracranial vessels and dura mater and the peripheral terminals of
the trigeminal nerve that innervate these structures (trigeminovascular
system)
• The caudal portion of the trigeminal nucleus
• Rostral pain-processing regions, such as the ventroposteromedial thalamus
and the cortex
• The pain-modulatory systems in the brain that modulate input from
trigeminal nociceptors at all levels of the pain-processing pathways and
influence vegetative functions, such as hypothalamus and brainstem
structures
PRIMARY HEADACHE

8. CLINICAL EVALUATION OF ACUTE, NEW-ONSET
HEADACHE
• HEADACHE Symptoms THAT Suggest A Serious underlying Disorder
• Sudden-onset headache
• First severe headache
• “Worst” headache ever
• Vomiting that precedes headache
• Subacute worsening over days or weeks
• Pain induced by bending, lifting, cough Pain that disturbs sleep or presents immediately upon
awakening
• Known systemic illness
• Onset after age 55
• Fever or unexplained systemic signs
• Abnormal neurologic examination
• Pain associated with local tenderness, e.g., region of temporal artery

9. • A careful neurologic examination is an essential first
step in the evaluation.
• patients with an abnormal examination or a history of
recent-onset headache should be evaluated
• CT and MRI methods appear to be equally sensitive.
• a lumbar puncture (LP) is also required, unless a
benign etiology can be otherwise established.
• The psychological state of the patient should also be
evaluated because a relationship exists between head
pain and depression.

10. • A general evaluation of acute headache might include
• cranial arteries by palpation;
• cervical spine by the effect of passive movement of the
head and by imaging;
• the investigation of cardiovascular and renal status by
blood pressure monitoring and urine examination;
• eyes by funduscopy, intraocular pressure measurement,
and refraction.

12. Diagnostic criteria for migraine
Migraine without aura
A. At least five attacks fulfilling criteria B through D
B. Headache attacks lasting 4 to 72 hours (untreated or
unsuccessfully treated)
C. Headache has at least two of the following characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity (eg,
walking or climbing stairs)
D. During headache at least one of the following:
- Nausea, vomiting, or both
- Photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
ICHD-3: International Classification of Headache Disorders, 3rd edition.

13. Migraine with aura
A. At least two attacks fulfilling criterion B and C
B. One or more of the following fully reversible aura symptoms:
- Visual, Sensory, Speech, and/or language,
- Motor, Brainstem, Retinal
C. At least three of the following six characteristics:
- At least one aura symptom spreads gradually over ≥5 minutes
- Two or more symptoms occur in succession
- Each individual aura symptom lasts 5 to 60 minutes
- At least one aura symptom is unilateral
- At least one aura symptom is positive
- The aura is accompanied or followed within 60 minutes by headache
D. Not better accounted for by another ICHD-3 diagnosis

15. CHRONIC DAILY HEADACHE

16. SECONDARY HEADACHE
• Meningitis
• Acute, severe headache with stiff neck and fever.
• LP is mandatory.
• Often there is striking accentuation of pain with eye movement.
• Meningitis can be easily mistaken for migraine in that the cardinal symptoms
of pounding headache, photophobia, nausea, and vomiting are frequently
present

17. • INTRACRANIAL Hemorrhage
• Acute, severe headache with stiff neck but without fever.
• A ruptured aneurysm, arteriovenous mal- formation, or intraparenchymal
hemorrhage may also present with headache alone.
• Rarely, if the hemorrhage is small or below the foramen magnum, the head
CT scan can be normal. Therefore, LP may be required to definitively diagnose
subarachnoid hemorrhage.

18. • Glaucoma
• may present with a prostrating headache associated with nausea and
vomiting.
• The headache often starts with severe eye pain.
• On physical examination, the eye is often red with a fixed, moderately dilated
pupil.

19. THANK YOU