E-Case 4-C

Jane Yeh, M.D.

January 28- February 8, 2002

28 yo woman who is establishing care reports intermittent headaches forabout 10 years.  They have occurred in increasing frequency since the birth of her child 10 months ago.  They started shortly after the delivery.   She reports they are bitemporal in location and not associated with photophobia, nausea, or vomiting.  They usually occur in the early evening when she comes home from work.  Her only medical history is of her recent normal pregnancy and vaginal delivery without complications.   Her physical examination, including neurological exam, is entirely normal.

How would you proceed?

Warning signs:

1. New severe headache (including a different headache from previous)
2. Headaches on exertion or early morning symptoms
3. Headaches that are progressive
4. Associated with fever, neck stiffness, or systemic symptoms
5. Headaches with neurological abnormalities
6. Precipitation of headache with Valsalva, coughing/sneezing, bending over
7. Very elderly or very young children (most primary headaches begin inchildhood or ages 20-50)

If one or more warning signs are present, consider checking CBC, ESR, drug screen, CT or MRI imaging, lumbar puncture.

Secondary Causes of Headaches:

1. Post-traumatic
2. Post lumbar puncture
3. Subarachnoid hemorrhage
4. Ischemic stroke
5. Temporal arteritis
6. Unruptured vascular malformation
7. Arterial hypertension
8. Venous thrombosis
9. Benign intracranial hypertension
10. Intracranial infection
11. Substance abuse related or withdrawal related
12. Metabolic disturbances (hypoxia, hypercapnea, hypoglycemia)
13. Facial pain
14. Cranial neuralgias
15. Medication related (over 1000 meds in the PDR have headache as apossible side effect)

Primary Headache Types

1. Tension
   • Lasts 30 minutes to 7 days
   • Pressing/tightening (nonpulsating)
   • Bilateral location
   • Not aggravated by routine physical activity such as walking stairs
   • Not usually associated with nausea or vomiting, photophobia or phonophobia
2. Migraine
   1. without aura,lasts 4-72 hours, often unilateral, pulsating, and aggravated by physical activity. May be associated with nausea/vomiting, photophobia or phonophobia.
   2. with aura at least 1 fully reversible aura symptoms including focal cerebral orbrainstem dysfunction; headache follows aura.
3. Cluster
   • Severe unilateral orbital, supraorbital, or temporal pain
   • Lasts 15 minutes to 3 hours
   • Up to 8 attacks per day or as few as 1 attack every other day
   • Associated with at least 1 of the following:
     • conjunctival injection
     • lacrimation
     • nasal congestion
     • rhinorrhea
     • forehead/facial sweating
     • miosis
     • ptosis
     • eyelid edema

References

Clinch CR.  Evaluation of Acute Headaches in Adults.  American FamilyPhysician.  2001; 63:685-92.