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Pain-Sensitive Structures and Their Projections
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Headache is caused by traction, displacement, inflammation, or distention of pain-sensitive structures in the head or neck. Disorders of the scalp, teeth, eyes, and ears and of the mucous membranes of the nose, sinuses, and oropharynx can produce pain. Pain-sensitive structures about the calvarium include the scalp and its blood vessels, the neck muscles, and the upper cervical nerves. The skull, brain, and most of the dura are not pain sensitive. In general, discrete intracranial lesions above the cerebellar tentorium produce pain in trigeminal distribution (anterior to ears), whereas lesions in the posterior fossa project pain to the second and third cervical dermatomes (posterior to ears).
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Chronic headache (duration of months or more) is usually not due to a serious disorder, but headache of acute onset or of a changing pain pattern demands prompt evaluation in the emergency department. If the patient has a chronic headache disorder, determine whether the present headache differs from or is identical to the patient's chronic problem. Headaches in the early morning or those causing waking may indicate an increase in intracranial pressure and prompt an evaluation for intracranial tumor.
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Family History of Headaches
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Primary headache disorders such as migraine and tension headaches commonly have a family history of headaches.
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Migraine or the Cluster Variant
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Hemicranial or retroocular pain.
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Commonly diffuse, occipital, or bandlike pain.
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Often focal (“right here”).
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Stabbing pain localized to the second or third division of the trigeminal nerve.
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Migraine or the Cluster Variant
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Commonly described as throbbing and often preceded by prodromal symptoms or auras, for example, scintillating scotomas or other visual changes.
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Tension Headache and Mass Lesion Headache
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A shooting or stabbing character.
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Commonly maximal on awakening.
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Cluster Variant of Migraine
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Frequently awaken patients from sleep and often recur at the same time of day or night.
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May develop at regular intervals, especially with recurrent stressful situations.
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Factors Influencing Severity
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Migraine or the Cluster Variant
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Frequently relieved by pressure on the ipsilateral temporal or carotid artery; by darkness, sleep, or vomiting; or during pregnancy.
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Often exacerbated by events such as coughing and sneezing that transiently raise intracranial pressure.
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Precipitating Factors
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Tension, emotional stress, and fatigue.
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Hunger, nitrite-containing foods (hot dogs, salami, sausage), chocolate, aged cheeses, bright lights, menses, alcohol, caffeine, monosodium gluta-mate, aspartame, and insomnia.
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Cluster Variant of Migraine
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Trigeminal Neuralgia and the Jaw Claudication of Temporal Arteritis
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Nausea or vomiting is common with migraine and posttraumatic headache syndromes and may be seen late in the course of mass lesions. Photophobia is prominent with migraine headache but occurs also with meningitis, especially viral (aseptic) meningitis. Myalgias of pericranial muscles (eg, posterior neck muscles) often accompany tension headaches and viral syndromes. Rhinorrhea and lacrimation during headache typify the cluster variant of migraine and are ipsilateral to the pain.
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Previous Diagnostic Tests
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Has the headache that the patient is presenting with previously been evaluated, and what tests (CT scan, MRI, lumbar puncture, pertinent laboratory data) have been performed?
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Response to Medication
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Find out what medications have worked in the past for this patient and if the patient commonly takes medications for prevention of headache. Clinical response of decreased pain to a medication should no be used as a lone indicator of a benign etiology of the headache.
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The presence of fever supports a diagnosis of meningitis, encephalitis, or headache associated with viral infection. A low-grade fever may also occur in temporal arteritis.
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Hypertension per se rarely causes headache, but chronic hypertension is the major risk factor for stroke, especially intracerebral hemorrhage. Intracerebral hemorrhage may be associated with acute headache. Blood pressure may be markedly elevated during hypertensive encephalopathy or as a result of preeclampsia–eclampsia, subarachnoid hemorrhage, or brain-stem stroke.
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Neurofibromas or café au lait spots of Recklinghausen disease may be associated with benign or malignant intracranial tumors.
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Cutaneous angiomas sometimes accompany arteriovenous malformations of the central nervous system; rupture results in subarachnoid hemorrhage and acute headache.
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Note nodularity or tenderness compatible with temporal arteritis.
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Note tenderness, erythema of overlying skin, or nasal discharge.
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Temporomandibular Joints
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Look for tenderness or limitation of motion.
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A bruit heard when the stethoscope is placed on the eyeball over closed eyelids may suggest intracranial arteriovenous malformation.
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Cervical muscle spasm may be a sign of tension or may occur with migraine.
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Can the patient touch chin to sternum? If not, is the limitation of motion mainly in the anteroposterior direction, suggesting meningeal irritation, or in all directions, as is common with cervical spine disorders? Is there any discomfort, neck flexion, or contralateral knee flexion during straight leg raising (Kernig sign)? Most important, is there even slight flexion of the knee (Brudzinski sign) during passive neck flexion?
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Meningeal signs may be absent or difficult to demonstrate in the early stages of subacute meningitis and may be very minimal in very young or older patients. Several hours may elapse before evidence of meningeal irritation develops after subarachnoid hemorrhage, and these signs disappear if the patient lapses into deep coma.
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Neurologic Examination
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Unilateral cranial nerve, cerebellar, motor, or reflex abnormalities suggest a diagnosis of intracranial mass lesion.
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Miscellaneous Physical Findings
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Papilledema, the hallmark of increased intracranial pressure, should always be sought. Acute confusion or altered consciousness is common after subarachnoid hemorrhage and with purulent meningitis.
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Indications for Imaging in the ED
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The following are indications to order no contrast CT scans in patients presenting to the ED with an acute headache:
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Abnormal neurologic exam to include altered mental status, cognitive impairment, or a focal deficit.
Patients experience a new severe headache of sudden onset.
HIV positive patients with a presentation of a new headache.
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