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Figure 20–1.
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Management of complaints of headache.

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Has Head Trauma Occurred?

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If recent head trauma has occurred, evaluation of this problem takes precedence (Chapter 22).

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Have Seizures Occurred?

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Patients may have headache following one or more grand mal seizures. However, because the seizures may themselves be due to serious underlying disease (eg, subdural hematoma), evaluation of this problem takes precedence (Chapter 19).

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Are There Focal Neurologic Abnormalities?

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The presence of new focal neurologic abnormalities with headache, especially if papilledema is present as well, is strongly suggestive of a mass lesion (tumor, hematoma, abscess). Computed tomography (CT) scan or magnetic resonance imaging (MRI) should be done as soon as possible to make the diagnosis. Further evaluation is discussed in Chapter 37.

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Is Headache New or of Acute Onset?

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The single most important item of information to obtain from a patient with headache is whether the headache is new or acute in onset. A new headache is one occurring in a patient without a history of headaches, or a novel pattern or quality of pain in a patient with a history of headaches. A headache that is acute in onset is far more likely to have underlying pathology that may be life-threatening requiring prompt investigation.

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Is the Complaint Consistent with Meningitis or Meningeal Irritation?

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If the headache is acute or subacute in onset, subarachnoid hemorrhage or meningitis must be suspected. The usual manifestations are signs of meningeal irritation (stiff neck; positive Kernig and Brudzinski signs) and fever. These findings may be minimal or even absent in very young or very old patients. Seizures, confusion, or coma may be present as well. Subarachnoid hemorrhage should be strongly suspected in a patient with abrupt onset of headache that is unique to the patient's experience, especially if meningeal irritation or focal neurologic findings are present. An emergency CT scan is the initial test of choice. However, as many as 2% of patients with subarachnoid hemorrhage can have a normal CT scan within the first 12 hours after the hemorrhage begins. If the diagnosis is unclear, lumbar puncture should be performed.

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Meningitis should be strongly suspected in a patient who presents with headache accompanied by fever, especially if signs of meningeal irritation are present. Antibiotic therapy should be started as soon as possible (based on microorganisms most common for each age group) before the CT scan or lumbar punctures are performed (Chapter 42). However, if there are signs of focal neurologic findings in a patient with fever, a brain abscess should be suspected and the lumbar puncture (but not antibiotics) should be delayed until a CT scan is performed.

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