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Evaluation of the Patient Presenting with Headache
Heatlache
0025--7 125/91 80.00
+
.20
Evaluation of the Patient Presenting with Headache Brian E. M01lclell , MD *
A complete history, a thorough physical examination, and appropriate diagnostic studies arc required for the evaluation of the patient presenting with headache. A carefully obtained history yields a provisional diagnosis that may be borne out by physical examination and, perhaps, allied diagnostic studies. The course of the patient's illness should be carefully documented . This anamnesis can provide the best clue to etiology.
HISTORY A complete headache history may be difficult to obtai n. Onc should use direct and indirect questioning in order to ensure that all pertinent facts arc uncove red. Although it is very important to allow patients to relate the story of their hca{laches in their own terms, qualification and focUS ing oflli storical facts arc the responsibility of the person taking the history. Present lIIness One should record the particulars from a headache history in a logical manner
so that a pattern evolves, permitting the identification of the typc(s) of hcadache.
A useful first step in the approach to headache is the dete rm ination of acuit y. Acute headache often may be ominous. It may be the expression of an intracranial disorder such as meningitis or encephalitis, subarachnoid hemorrhage, subdural he matoma, or tumor. Extracranial pathology may be Similarly expressed as acute headache, e.g., glaucoma, intra- or extraocular infl ammation, optic neuritis, and acute sinusitis. Acute headache may also be associated with systemic disorders, as seen in hypertension or pheochromocytoma. Subacute headache may be the presenting complaint of subdural hematoma, cerebral abscess, tumor, intracranial sinus thrombosis, benign intracranial ilypcrtension, giant cell arte ritis, and hypo- or hypcrtilyroidism. Chronic headacile most commonly represents a migraine or muscle contraction headache, but it has also, on occasion, been the result or metabolic, systemic, or malignant disease. Important factors in the documentation or present illness include onsct, ·Assistant professor of Neurology, The Johns Hopkins University School of M,--dicinc; and Medical Dir~tor . Baltimore lIeadache Institute. Baltimore. Maryland Medico/ Clinics of North Americo-Vol. 75. No. 3. May 1991
521
522
BHJAN
E ......10NOE!..L
frequency, intensity, location, (IUality, prccipitators or cl'accrhators, amcl iorators, associated sym ptoms. and neurologic accompaniments. Onset. Establish the Ollset of headache hy as king about the carl iest memory of Ilcaclache. determining whether the headache occurred in childhood or later in life, or after a traumat ic episode. Is headache a new event or one of a recurrent series? Is it present on awakening, or does it occur at night and awaken the patient? Since onset, have the essent ial characteristics remained the same? Frequency. Dete rmine the frequency of headache, looking for patterns of occurrence or recurrence at regular intervals. Duratioll. Ascertain the duration of headache. not ing the longest, shortest, and average length of an attack. Intensity. Find out the intensity of headache, distinguishing hetween mild, moderate, severe, or incapacitating pain. Pain is best measured by its effect on the activi ties of daily living. ~Hld pain implies minimal restriction. ~'I ooe rat c pain impl ies medium restriction. Severc paiu implies significant restriction. Incapacitating pain implies total restriction. U:Jcation_ Specify the IOClltiOn of headache, recording where the pllin starts, where the pain radiates, aud where the pain settles. Qlwlity. Define the quality of pain using the follOWing adjectives: aching, boring, buming, expanding, gnawing, piercing, pounding, pressing, squeezing, stabbing, throbbing. Precipit"tors or Exacerbators. List the precipitators or cxacerbators of headache , noting multiple factors such as alco hol, changes in barometric prcssure, bend ing over, bright lights, chewing, coughing, exertion. fa tigue, foods , head jarrin g, hunger, loud noises, menarche, menopause. menstruation, odOTS , position. sexual activity, sleep habits, sneezing, straining, stress, and touching. Ame/ioralors. Ilecord the amcliorators of headache, indicating whllt has been done to relicve or reduce pain . including previous treat ment. Associatell Sym,1toms, Enumerate the associated symptoms of headache, including bruxism, chills, clicking jaw, cold hands or fee t, conjunctival injection , facial ederna, fatigue, fever, Rushing, lacrimation, malaise, nasal ('()ngestion, nausca, pallor. polyuria, rhinorrhea. scalp tcndemess, amI vomi ting. Neurologic AecOllllXlnimellts. Describe the neurologic accompan ime nts that occur in association with headache e ithe r before, during, or after an attack, such as amnesia, ataxia. blindness, bluTTe<1 lIision, confusion,
EVALUATION OF TilE PATIENT PRESI::NTlNG
wrnl
H I::AIHCHE
523
Personal and Social History l11e patient's personal and social history needs to be taken into consideration. Question the patient about home environment as a youth, including abuse and neglect, and parental divorce or separation. The reinforcing reaction of family or fr iends to e pisodes of pain and d isabilities wi th sympathy and attention may set the stage for future maladaptive behavior. Socioeconomic class, cultural and educational background, occupation , marital status, adjus tment to family life, general life satisfaction, military service. travel, and other exposure arc also important. Personal habits such as diet, regularity of eat ing and sleeping, exercise. quantity of coffee, tea, and other caffeine-containing beverages consumed, as well as use of tobacco, alcohol, illicit drugs need to be reviewed. Specifically, one should consider the effect of life events upon the patient. Frustrating or irritating demands posed by everyday events should command as much attention as major unfavorable events. The presence of less successful strategies for coping-avoidance or self-criticism-may be important in the evolution of headache, as might hypochrondriacal or neurotic worry about what has happened and what might happen in the futu re. Also important is the search for obsessionality and hostility. Depression of mood and associated sleep disturbance above and beyond what is a reasonable response to headache also are important to observe. Does inability to deal with stress cause a breakdown in coping mechanisms and a susceptibility to headache, or arc such maladaptive I>crsonality responses the result of the experience of headache? Systems Review A comprehensive review of systelns completes d lC headache history. Inquiry should be made regarding each of the follOWing areas: general constitutional symptoms, skin . skeletal, eyes, cars, nose, throat, mouth, endocrine, respiratory, cardiac, hematologic, lymph nodes, gastrointestinal, genitourinary, neurologic, and psychiatric. This review serves as a useful method to sort out a headache history, which can be vague, complicated, or even contradictory. u PHYSICAL EXAM INATIO N
Although a careful history often suggests a spccific diagnosis, a complete physical and neurologic examination is necessary to confirm a suspected diagnosis. The palient"s general condition needs to be characterized, with a description including evidence of pain, restlessness, and mental state. Vital signs-temperat ure, pulse, respiration, blood pressure, he ight, and weight-should be recorded. One should inspect the skin for lesions, ras hes, and areas of pigmentation. Other features frOIll the general examination that need to be observed are positive findings in the chest, heart, abdomen, and extremities. The head must be examined thoroughly. Observe the size and shape of the head. The skull should be palpated for tenderness, protuberances, or depressions and auscultated at various points. Specifically, the carotid, temporal, and OCCipital arte ries should be palpated and auscultated. One should listen for orbital bruits. A thorough eye examination is mos t important. Attention should be given to the temporomandibular joints, fOCUSing on tenderness on pressure, limited opening of the mouth, or malocculusion. Finally. one should sce if the frontal or maxillary sinuses are tende r. The next area to be assessed is the cervical spine. The neck should be tested for tenderness and mobility with Aexion, extension, and rotation. The length of the cervical spine may also be important. Thyroid size and character should be recorded as well.
524
BRIM":
E.
~'I ONDELL
A neurologic examination must be completed . ~"enlal status examination should include assessment of orientation, memory, 1llO(X1, affect, speech ami articulation, and thought processes and pe rceptions. Scrutinize all cranial nerves . One should look fo r motor weakness, muscle wasting, alterations in muscle tone, and ahnormal move me nts. Any reflex changes or pathologic re fl exes must be described. C ait, posture, and coordination arc similarly noteworthy. finally, disturbances of sensory fUllction s need to be recognized .
DIAGNOSTIC STUDIES The concluding ()Ortion of the initial evaluation of tile patient presenting with headache involves the use of diagnostic studies. Investigation should include a routine laboratory proRle consisting of blood counts and chemistries, thyroid fun ction , and urinal ysis. ~'I easureme n t of eryth rocyte sedimentation rate may be nccessary. Evidence suggesting infection or hc morrhagc should prompt spinal nui(] examination. Neuroimaging studies such as compuled axial tomogra phy, magnetic resonance imaging, and cerebral angiography should be used selecti vely an(1 reserved for cases in which history and cxam ination indicate a structural lesion . SUM MARY In order to treat the patient presenting with headache successfully, onc must carefully question, examine, and stud y the com ple te patient as well as his or her complaint of headache. Through direct and indirect questioning, a complete history may be obtained by exploring present illness, past medical history, family history, personal and social histo ry, and systems review. A detailcd med ical and ne urologic examination is also neccssary to evaluate tllc complaint of beadachc. A oompre hcllsive screening laboratory profile should be c mployed, but neurodiagnostic studies should onl y be used judiciously. A combined mcdical a nd neurologic appro.1cb will permit appropriate idc ntification and cffectivc treatmc nt of the specific bcadadlC d isorde r rathcr t han the isolate d complaint of headache . REF ERENCES I. Blau I N: How to take a hi story or head or r."lCial pain. Br Med J 285: 1249- 1251. 1982 2. Brodman K, Erdmann Al , Large I. et al: The Cornell medical index: An adjullct to medical interview. lAMA 140:530-534. 1949 3. Brodman K. Erdrnann AI , Large I. et al: The Cornell medical index-health questionnai re. 11. As a diagnos tic instrume nt. JAMA 145: 152-157. 1951
Address repri nt requests to Brian E. Mondell. MD Baltimore Headache Institute 11 E. C hase Street. Suite lA Baltimore, MD 21202
0025--7 125/91 80.00
+
.20
Evaluation of the Patient Presenting with Headache Brian E. M01lclell , MD *
A complete history, a thorough physical examination, and appropriate diagnostic studies arc required for the evaluation of the patient presenting with headache. A carefully obtained history yields a provisional diagnosis that may be borne out by physical examination and, perhaps, allied diagnostic studies. The course of the patient's illness should be carefully documented . This anamnesis can provide the best clue to etiology.
HISTORY A complete headache history may be difficult to obtai n. Onc should use direct and indirect questioning in order to ensure that all pertinent facts arc uncove red. Although it is very important to allow patients to relate the story of their hca{laches in their own terms, qualification and focUS ing oflli storical facts arc the responsibility of the person taking the history. Present lIIness One should record the particulars from a headache history in a logical manner
so that a pattern evolves, permitting the identification of the typc(s) of hcadache.
A useful first step in the approach to headache is the dete rm ination of acuit y. Acute headache often may be ominous. It may be the expression of an intracranial disorder such as meningitis or encephalitis, subarachnoid hemorrhage, subdural he matoma, or tumor. Extracranial pathology may be Similarly expressed as acute headache, e.g., glaucoma, intra- or extraocular infl ammation, optic neuritis, and acute sinusitis. Acute headache may also be associated with systemic disorders, as seen in hypertension or pheochromocytoma. Subacute headache may be the presenting complaint of subdural hematoma, cerebral abscess, tumor, intracranial sinus thrombosis, benign intracranial ilypcrtension, giant cell arte ritis, and hypo- or hypcrtilyroidism. Chronic headacile most commonly represents a migraine or muscle contraction headache, but it has also, on occasion, been the result or metabolic, systemic, or malignant disease. Important factors in the documentation or present illness include onsct, ·Assistant professor of Neurology, The Johns Hopkins University School of M,--dicinc; and Medical Dir~tor . Baltimore lIeadache Institute. Baltimore. Maryland Medico/ Clinics of North Americo-Vol. 75. No. 3. May 1991
521
522
BHJAN
E ......10NOE!..L
frequency, intensity, location, (IUality, prccipitators or cl'accrhators, amcl iorators, associated sym ptoms. and neurologic accompaniments. Onset. Establish the Ollset of headache hy as king about the carl iest memory of Ilcaclache. determining whether the headache occurred in childhood or later in life, or after a traumat ic episode. Is headache a new event or one of a recurrent series? Is it present on awakening, or does it occur at night and awaken the patient? Since onset, have the essent ial characteristics remained the same? Frequency. Dete rmine the frequency of headache, looking for patterns of occurrence or recurrence at regular intervals. Duratioll. Ascertain the duration of headache. not ing the longest, shortest, and average length of an attack. Intensity. Find out the intensity of headache, distinguishing hetween mild, moderate, severe, or incapacitating pain. Pain is best measured by its effect on the activi ties of daily living. ~Hld pain implies minimal restriction. ~'I ooe rat c pain impl ies medium restriction. Severc paiu implies significant restriction. Incapacitating pain implies total restriction. U:Jcation_ Specify the IOClltiOn of headache, recording where the pllin starts, where the pain radiates, aud where the pain settles. Qlwlity. Define the quality of pain using the follOWing adjectives: aching, boring, buming, expanding, gnawing, piercing, pounding, pressing, squeezing, stabbing, throbbing. Precipit"tors or Exacerbators. List the precipitators or cxacerbators of headache , noting multiple factors such as alco hol, changes in barometric prcssure, bend ing over, bright lights, chewing, coughing, exertion. fa tigue, foods , head jarrin g, hunger, loud noises, menarche, menopause. menstruation, odOTS , position. sexual activity, sleep habits, sneezing, straining, stress, and touching. Ame/ioralors. Ilecord the amcliorators of headache, indicating whllt has been done to relicve or reduce pain . including previous treat ment. Associatell Sym,1toms, Enumerate the associated symptoms of headache, including bruxism, chills, clicking jaw, cold hands or fee t, conjunctival injection , facial ederna, fatigue, fever, Rushing, lacrimation, malaise, nasal ('()ngestion, nausca, pallor. polyuria, rhinorrhea. scalp tcndemess, amI vomi ting. Neurologic AecOllllXlnimellts. Describe the neurologic accompan ime nts that occur in association with headache e ithe r before, during, or after an attack, such as amnesia, ataxia. blindness, bluTTe<1 lIision, confusion,
EVALUATION OF TilE PATIENT PRESI::NTlNG
wrnl
H I::AIHCHE
523
Personal and Social History l11e patient's personal and social history needs to be taken into consideration. Question the patient about home environment as a youth, including abuse and neglect, and parental divorce or separation. The reinforcing reaction of family or fr iends to e pisodes of pain and d isabilities wi th sympathy and attention may set the stage for future maladaptive behavior. Socioeconomic class, cultural and educational background, occupation , marital status, adjus tment to family life, general life satisfaction, military service. travel, and other exposure arc also important. Personal habits such as diet, regularity of eat ing and sleeping, exercise. quantity of coffee, tea, and other caffeine-containing beverages consumed, as well as use of tobacco, alcohol, illicit drugs need to be reviewed. Specifically, one should consider the effect of life events upon the patient. Frustrating or irritating demands posed by everyday events should command as much attention as major unfavorable events. The presence of less successful strategies for coping-avoidance or self-criticism-may be important in the evolution of headache, as might hypochrondriacal or neurotic worry about what has happened and what might happen in the futu re. Also important is the search for obsessionality and hostility. Depression of mood and associated sleep disturbance above and beyond what is a reasonable response to headache also are important to observe. Does inability to deal with stress cause a breakdown in coping mechanisms and a susceptibility to headache, or arc such maladaptive I>crsonality responses the result of the experience of headache? Systems Review A comprehensive review of systelns completes d lC headache history. Inquiry should be made regarding each of the follOWing areas: general constitutional symptoms, skin . skeletal, eyes, cars, nose, throat, mouth, endocrine, respiratory, cardiac, hematologic, lymph nodes, gastrointestinal, genitourinary, neurologic, and psychiatric. This review serves as a useful method to sort out a headache history, which can be vague, complicated, or even contradictory. u PHYSICAL EXAM INATIO N
Although a careful history often suggests a spccific diagnosis, a complete physical and neurologic examination is necessary to confirm a suspected diagnosis. The palient"s general condition needs to be characterized, with a description including evidence of pain, restlessness, and mental state. Vital signs-temperat ure, pulse, respiration, blood pressure, he ight, and weight-should be recorded. One should inspect the skin for lesions, ras hes, and areas of pigmentation. Other features frOIll the general examination that need to be observed are positive findings in the chest, heart, abdomen, and extremities. The head must be examined thoroughly. Observe the size and shape of the head. The skull should be palpated for tenderness, protuberances, or depressions and auscultated at various points. Specifically, the carotid, temporal, and OCCipital arte ries should be palpated and auscultated. One should listen for orbital bruits. A thorough eye examination is mos t important. Attention should be given to the temporomandibular joints, fOCUSing on tenderness on pressure, limited opening of the mouth, or malocculusion. Finally. one should sce if the frontal or maxillary sinuses are tende r. The next area to be assessed is the cervical spine. The neck should be tested for tenderness and mobility with Aexion, extension, and rotation. The length of the cervical spine may also be important. Thyroid size and character should be recorded as well.
524
BRIM":
E.
~'I ONDELL
A neurologic examination must be completed . ~"enlal status examination should include assessment of orientation, memory, 1llO(X1, affect, speech ami articulation, and thought processes and pe rceptions. Scrutinize all cranial nerves . One should look fo r motor weakness, muscle wasting, alterations in muscle tone, and ahnormal move me nts. Any reflex changes or pathologic re fl exes must be described. C ait, posture, and coordination arc similarly noteworthy. finally, disturbances of sensory fUllction s need to be recognized .
DIAGNOSTIC STUDIES The concluding ()Ortion of the initial evaluation of tile patient presenting with headache involves the use of diagnostic studies. Investigation should include a routine laboratory proRle consisting of blood counts and chemistries, thyroid fun ction , and urinal ysis. ~'I easureme n t of eryth rocyte sedimentation rate may be nccessary. Evidence suggesting infection or hc morrhagc should prompt spinal nui(] examination. Neuroimaging studies such as compuled axial tomogra phy, magnetic resonance imaging, and cerebral angiography should be used selecti vely an(1 reserved for cases in which history and cxam ination indicate a structural lesion . SUM MARY In order to treat the patient presenting with headache successfully, onc must carefully question, examine, and stud y the com ple te patient as well as his or her complaint of headache. Through direct and indirect questioning, a complete history may be obtained by exploring present illness, past medical history, family history, personal and social histo ry, and systems review. A detailcd med ical and ne urologic examination is also neccssary to evaluate tllc complaint of beadachc. A oompre hcllsive screening laboratory profile should be c mployed, but neurodiagnostic studies should onl y be used judiciously. A combined mcdical a nd neurologic appro.1cb will permit appropriate idc ntification and cffectivc treatmc nt of the specific bcadadlC d isorde r rathcr t han the isolate d complaint of headache . REF ERENCES I. Blau I N: How to take a hi story or head or r."lCial pain. Br Med J 285: 1249- 1251. 1982 2. Brodman K, Erdmann Al , Large I. et al: The Cornell medical index: An adjullct to medical interview. lAMA 140:530-534. 1949 3. Brodman K. Erdrnann AI , Large I. et al: The Cornell medical index-health questionnai re. 11. As a diagnos tic instrume nt. JAMA 145: 152-157. 1951
Address repri nt requests to Brian E. Mondell. MD Baltimore Headache Institute 11 E. C hase Street. Suite lA Baltimore, MD 21202