Highlights of the 5th Annual Association of Family Practice Physician Assistants (AFPPA) Conference: Headache Management -- Evaluation and Treatment

San Antonio, Texas; November 19-23, 2003

Jim Meeks, PA-C


February 12, 2004

In This Article

Evaluation of Headache

Differentiation of headaches can be difficult and occasionally confusing. There is a tendency for symptoms of the various headache types to overlap, thus making the correct diagnosis a challenge for the primary care provider.

Initial evaluation of the headache patient requires collecting a complete medical history. Specific questioning regarding the patient's headache will often lead to a diagnosis without elaborate testing. Nett reviewed 3 specific questions that can aid in the diagnosis of migraine, stating that this simple evaluation was recently published in the journal Neurology.[10]

  1. Does the patient have nausea? (82% sensitive)

  2. Is the headache affected by light, sound, or smell? (80% sensitive)

  3. Does increased activity cause increased headache? (80% sensitive)

An affirmative response to any 2 of the 3 questions is 87% sensitive for diagnosis of migraine headache. If all 3 responses are affirmative, the sensitivity for diagnosis is 97%.[10]

Other important elements of the history include onset and progression and intensity, location, and duration of pain. Contributing factors to consider include consumption of caffeine, nicotine, and alcohol, or tyramine-containing foods that have been linked to migraine headaches.[8]

The medical history becomes more important when one considers that the extent of comorbidity in migraineurs is greater than that seen in the general population: Depression is 3 times more common, anxiety and panic disorder are 6-8 times more common, irritable bowel syndrome is 8 times more common, and stroke is 4 times more common in migraineurs.[4]

Laboratory evaluation to rule out thyroid disease and anemia is recommended as part of the evaluation of headache. Treatment of these conditions, if identified, may reduce the number of headache episodes. Unger and colleagues[11] recommend that migraine patients with aura be tested for the presence of anticardiolipin antibodies. A positive test indicates increased potential for stroke, and these patients should be placed on prophylactic aspirin if they smoke and/or use oral birth control pills. They should be counseled to stop smoking immediately, and hormonal contraception should be used only with informed consent because of this increased risk.[11]

Assessment of the patient's sleeping habits is equally important to the headache evaluation. It is also important to solicit any history of neurosurgery or neurologic disorders, seizure, neoplasm, psychiatric disturbances, hypertension, or stroke.

An appropriate physical exam is essential. The basic elements of the exam should include vital signs; palpation of the cranium for abnormalities or tenderness; ophthalmoscopic examination (including fundi); ears, nose, and throat; and a neurologic exam. Other physical examination elements should be performed as indicated by the history and clinical presentation of the patient. The goal of the history and physical evaluation is to rule out findings suggestive of secondary headache pathology.[8]

Schuman[1] identified 6 specific "headache alarms":

  1. Abnormal neurologic examination findings

  2. Patient age > 50 years

  3. First or worst sudden, severe headache

  4. Seizure

  5. Change in level of consciousness

  6. Cancer or AIDS diagnosis

Schuman emphasized the "first or worst" statement in conjunction with subarachnoid hemorrhage, stating that syncope, falls, head injuries, hypertension, and arrhythmias are common in the patients who claim that the headache they are describing is the first of a particular type or the worst they have ever experienced. Either of these descriptions should lead immediately to a more detailed evaluation of the patient.[1] A CT scan performed within the first 24 hours of onset of symptoms is 93% to 100% accurate in diagnosing subarachnoid hemorrhage. Up to 85% of scans may be positive if done within 5 days. This percentage drops to 50% at 7 days.

When the CT scan is negative, equivocal, or technically inadequate and the clinical presentation is consistent with or suspicious for subarachnoid hemorrhage, it is recommended that the patient be evaluated with a lumbar puncture (LP). Twenty percent of LPs result in a traumatic tap, contaminating the spinal fluid with red blood cells. Schuman[1] recommends that if that happens, the LP should be repeated at a site 1 vertebral body interspace higher than the site of the first LP. He maintains that repeating the tap at a higher site is the best method for differentiating a traumatic LP from a subarachnoid hemorrhage.[12]

The American College of Emergency Physicians has established a clinical policy for the evaluation and management of patients presenting to emergency departments with acute headache; it provides excellent criteria for evaluation.[13] This clinical policy provides answers to specific questions regarding headache presentation that may be helpful in many clinical situations. I recommend review by every practitioner who evaluates patients with headache.


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