Clinical Problems of Headache

Assessment of the Patient with Headache

The interview and history are by far the most important parts of the assessment. It is very important to allow the patient to express feelings and fears and to ascertain his or her expectations of treatment and perception of the cause of the headache. The important data to be obtained from the history are length of headache  history, frequency of headaches, mode of onset, duration, site of headache, severity, description of pain, precipitating factors, warning symptoms, accompanying symptoms, relieving factors and coping strategies, history of trauma, current medications, and family history of headaches. If time is limited, anxiety to obtain all the data should not be allowed to reduce the opportunity for the patient to express himself or herself. If necessary, the full picture can be obtained over two or more visits.

Grouping a number of headache patients together in one category is an abstraction from a much larger picture. In each patient, the symptom of headache has to be considered in the larger context of the whole person. The family physician’s knowledge of the context may come from a number of sources but most probably from previous knowledge of the patient and the family and from the patient’s records. Any defi ciencies in this knowledge will need to be made up for during the initial visits. It is important to know about current problems in the patient’s life, previous illness patterns, and self-medication. A history of pain syndromes or a tendency to symptom formation is particularly important.

At the completion of the interview and history, the physician should already have ascertained, with a high probability of being correct, whether the headaches are primary or secondary and, if primary, whether they fall into the categories of migraine with aura or cluster headache. Texts on headache sometimes say that a full neurological examination should be done on every patient. For the primary physician this is poor advice. In most patients, a full neurological examination would be redundant and would only reduce the time available for listening to the patient. Apart from certain routines, the physical examination—its kind and extent—will be determined by the physician’s hypothesis after completing the interview and history. 

A hypothesis of sinusitis will direct the physician’s attention to the nose and sinuses; a headache of recent and sudden onset to the body temperature and a test for neck rigidity; a history of neurological symptoms to the appropriate neurological examination; and malaise accompanying the headaches to a search for infection. On the other hand, a patient with tight-band headache who breaks down and cries may have little or no physical examination at all. Besides a directed search, the physician should also have certain routines that are done for all patients or all patients in certain categories. 

These are not necessarily done on all patients; one or all may be omitted. The important thing is that the physician has to justify their omission to himself or herself. The routines headache patients may include pulse, blood pressure, fundi, selected cranial nerves, neck movements, palpation of neck and scalp, and, in patients over50 years, sedimentation rate. Hypertension seldom presents with headache; many patients, however, expect to have their blood pressure taken, and their visit provides an opportunity to detect hypertension unrelated to the headaches.

The Diagnosis of Headache

The family physician’s main tasks are to distinguish primary from secondary headache and, within these categories, to identify certain disorders with a specifi c etiology, specifi c therapy, or a threat to life.

Migraine with Aura

The distinguishing features of migraine with aura are recurrent headaches preceded or accompanied by focal neurological disturbances and also accompanied by nausea and/or vomiting. The headache is usually described as throbbing and severe and may be unilateral or bilateral. The frequency of the headaches varies greatly from one patient to another and in the same patient at different times. The most common neurological disturbances are visual. Typically, the patient fi rst notices a small area of scintillation and blurring in the fi eld of vision. This gradually enlarges into a ring of zig-zag lines, shaped like the fortifi cations of an ancient castle. Hence the term fortifi cation spectrum. 

The enlarging ring is followed by a crescent of blindness—the scotoma—which is followed in turn by restoration of vision. The whole sequence takes 15 to 20 minutes to pass over the visual fi eld. Typically, the headache begins as the aura wanes. Some patients may experience fl ashing lights, scotomata, or hemianopia. Others may have transient neurological disturbances of other kinds—paresthesia, vertigo, or aphasia, for example. The tongue, hands, and feet are areas of predilection for paresthesia.

These begin peripherally and spread centripetally. The rate of spread is very much slower than in the aura of epilepsy—an important distinguishing feature. In contrast to the crescendo of migraine—transient ischemic attacks (TIAs) are maximal at onset, after which they recede. The anatomical distribution of a TIA corresponds to the distribution of the artery involved. Attacks of migraine—with or without aura—may be preceded by premonitory or prodromal symptoms such as restlessness, insomnia, emotional arousal, mood changes, thirst, water retention, and gastrointestinal disturbances. After the attack, there may be a period of cognitive disturbance during which it is unwise for the patient to be doing work that involves judgment and decision making. 

The prodromal symptoms can warn the patient to prepare for an attack. On the other hand, they may have a disturbing effect on the family. Migraine with aura usually begins in childhood or early adult life. Onset after the age of 50 is rare. The pattern of attacks varies greatly between patients and in the same patient at different periods of life. Some patients may have only occasional attacks throughout life. Some may have occasional attacks at one time of life, frequent attacks at another. Others may have the full syndrome at one
time of life and transient neurological symptoms without headaches at another. In childhood, the manifestation of migraine may be recurrent vomiting attacks (the periodic syndrome). In some patients, the pain may be felt in one side of the face—the so-called facial migraine. In certain rare variants of the migraine syndrome, the headaches are accompanied and followed by motor neurological defi cits such as hemiplegia or ophthalmoplegia. These motor phenomena require further pursuit.

Migraine without Aura

The attacks are distinguished from migraine with aura chiefl y by the absence of preceding neurological symptoms. The most common symptoms accompanying the headache are nausea, vomiting, photophobia, phonophobia, and general sensory excitability. Other symptoms include dizziness, drowsiness, abdominal pain, diarrhea, and nasal stuffi ness. If nausea is the only symptom accompanying the headache, differentiation from TTH may be diffi cult, especially if the headache is not typical of migraine. The
Headache Study Group found that only six patients out of 65 classifi ed as having common migraine were considered “defi nite” after 1 year of follow-up. Very frequent migraine (>15 days per month for at least 3 months) is called chronic migraine provided there is no medication overuse. Typically, chronic migraine evolves from migraine without aura.

Cluster Headache (Migrainous Neuralgia)

The salient features of cluster headache are its periodicity, its great severity, and its preponderance in males. The syndrome is periodic in two senses. Bouts of headaches, lasting from 2 to 12 weeks, alternate with pain-free intervals of several months to several years. Within each bout, headaches occur one or more times a day, often with great regularity. The headache is almost always unilateral and centered around the eye and is so severe that the sufferer cannot keep still. It is usually accompanied by lacrimation from the eye on the affected side. The conjunctiva is often injected in this eye, and there may be some drooping of the upper eyelid and miosis. If the patient is seen between headaches, these signs are of course absent. The male-to-female ratio in cluster headache is about 6 to 1. Most patients are between the ages of 20 and 40. 

Tension-type Headache and Recurrent Nonspecifi c Headache

The IHS (ICHD II) continues to include TTH, episodic and chronic, in its classifi cation system. The headache is defi ned by the features that distinguish it from migraine: moderate severity, bilateral distribution, longer duration, and absence of nausea and photophobia. The chronic form is distinguished from the episodic by the persistence of headaches for longer than 6 months. In addition, both episodic and chronic TTH are subdivided into those with and without pericranial tenderness elicited by manual palpation.
This classifi cation and nomenclature remains controversial. The physiological basis for these headaches has not been established, and in practice it is often diffi cult to make a clear distinction between common migraine and “tension-type” headaches. This diffi culty is refl ected in the discussions within the classifi cation
subcommittee of the International Headache Society( ICHD II, 2004, p. 32). The issue can be further complicated as TTH can occur in migraineurs making treatment decisions even more diffi cult.

After reviewing all the available clinical data in 265 new patients with headache, using the 1962 classifi cation, the Headache Study Group (1986) was unable to classify 50% of the patients with any degree of certainty. Thirty percent were classifi ed as having “possible muscle contraction headache” and 22% as “possible common migraine.” For these reasons, such patients were described in the fi rst edition of this book as having recurrent nonspecifi c headache (RNSH). Anxiety was associated with the headaches in about 60% of these patients and depression in about 25%. In many patients with RNSH, the headaches are related to transient situational anxiety and reactive depression. In some, the anxiety is focused on the cause of the headache. Of 1,331 patients attending primary care physicians with new headache, 1,131 (85%) did not return for a second visit within the 14-month study period (Becker et al., 1988). This suggests that in the great majority of patients with headache seen by family physicians, the condition is self-limiting or responds to measures such as reassurance and counseling. The following consultation is a good example of this type of headache.


Clinical Problems of Headache
Source: Familu Medicine
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