Patients suffering from headache - Qpercom

Introduction
Headache is a very common complaint. Many people who (now and again) suffer from headache do not consult a doctor. The patient is often aware of the cause of the headache (tension, bad night’s sleep, alcohol) and treats themself with rest and/or analgesics. If a patient consults a doctor it usually means they are concerned and think that their complaints are caused by a serious condition. The patient wants the doctor to find a cause for their complaint, if possible, and at the very least they hope the doctor can rule out serious (somatic) conditions.

History-taking
All headache patients should be asked the following important questions:

Duration and course

When and how did the pain begin?
Is the pain constantly present or does it come in attacks?
Is the pain present upon wakening or does it develop during the course of the day?
Has the pain become worse recently?
If the pain comes in attacks, how long does such an attack last?
Do you feel one of these headache attacks coming on in one way or another?
Do the attacks occur mainly during weekends and holidays?
Did something happen before you first starting suffering from headaches which could be the cause?

Location
Where in your head is the pain worst?

Nature
Is the headache

stabbing?
throbbing or hammering?
pressing?

Influencing factors
Does the pain get worse:

upon exertion?
with emotions?
when bending down?
with bright light?
when reading?
when watching television?
during menstruation?

Does the pain get better?

when you take painkillers?
or other medication?
after a good night’s sleep?
when the neck muscles are massaged?

Additional signs and symptoms
Prior to the pain have you experienced any of the following symptoms:

do you see flashing lights?
does your vision suddenly get much worse?
do you suffer from tingling in your face, arms or legs?
do you suffer from paralysis or loss of strength in your arms or legs?
is your sense of smell altered?

Do you suffer from one of the following complaints during the headache (attack):

do you shy away from light?
does your vision get worse?
do you vomit?
do you have a red, watery eye?
do you suffer from a runny nose?
do you suffer from loss of strength in your arms or legs?
do you suffer from dizziness?
do you suffer from ringing in your ears?
do you suffer from double vision?
do you have a temperature?
do you feel pain anywhere other than your head?

It is also important to inquire about the familial history of head-ache, the patient’s medication use, alcohol intake and use of other drugs, as well as previous illnesses, any periods of hospitalisation and operations.
If the history-taking does not reveal a somatic condition to be the cause of the headache, it is important to ask the patient whether the headache could be related to any problems the patient may have. Such a question must be asked in way that the patient retains the sense of being respected.

The examination

Generally you will have formed one or more hypotheses about the cause of the headache after this history-taking. The physical examination should be used to test these hypotheses.

Increased intracranial pressure
1. If you suspect increased intracranial pressure because:

The pain is primarily present in the morning.
The pain gets worse upon coughing, sneezing or bearing down.
The pain is accompanied by vomiting, you should carry out the following examination:
- Assess whether the patient’s state of consciousness is impaired (EMV score, see ‘The unconcious patient’).
- Measure the pulse rate and blood pressure (increased intracranial pressure can lead to a slow pulse rate and rising blood pressure).
- Examine the abducent nerve function and the oculomotor nerve function (refer to ‘The cranial nerves’).
- Carry out funduscopy to determine the presence of optic disc oedema.
- In children you should measure the circumference of the head and compare it with previous measurements.

Meningeal irritation
2. If you suspect meningeal irritation because

the onset of the pain was acute (like a ‘bang’ inside their head)
the pain is accompanied by fever
the pain was preceded by a middle ear infection, for example,

You should carry out the following examination:

Assess whether there is any sign of impaired consciousness.
Carry out the tests for meningeal irritation (refer to ‘Signs of meningeal irritation’).
Note 1: During the first hours following an arachnoidal haemorrhage, the meningeal irritation tests are often negative.
Note 2: In infants and small children with meningitis, the meningeal irritation tests (pain when putting on a diaper, pain when lifting out of bed) are often negative. The child will be apathetic and drowsy.
If you suspect an arachnoidal haemorrhage, you should carry out funduscopy to see whether there is any pre-retinal bleeding.
Note: pre-retinal bleeding only occurs in a small percentage of cases.

Migraine
3. If you suspect migraine because:

the pain occurs in attacks
the pain attacks occur primarily in the weekend or holidays or during menstruation
the patient is aware that the pain attacks are coming due to prodromal symptoms (flashing lights, poor vision, tingling, paralysis)
the pain is accompanied by nausea and vomiting
the pain is accompanied by photophobia
there is a family history of migraine,

There is unfortunately no physical diagnostic examination available to test your hypothesis.

Cluster headaches (Horton’s neuralgia)
4. If you suspect cluster headaches because

the pain occurs in attacks that last less than about 1.5 hours
the pain attacks often occur at night
the pain attacks occur in clusters (daily for a few weeks long and then symptome-free for months or years)
the pain is localised in or around one eye,

You should carry out the following examination:

During a pain attack assess whether it involves a cluster headache (miosis, ptosis, anhydrosis, enophthalmia).

Trigeminal neuralgia
5. If you suspect trigeminal neuralgia because

the pain occurs in short attacks of about 5-10 jabs of pain each time
the pain is localised in the 2nd or 3rd branch of the trigeminal nerve
the pain can be evoked by eating or lightly touching certain points around the nose or mouth, for example, the diagnosis will have to be based on the history-taking because examination will always show the trigeminal nerve to be intact.

Temporal arteritis (giant cell arteritis)
6. If you suspect temporal arteritis because

the pain is continuous
the nature of the pain is throbbing
the pain is located around the temple area
the pain occurs in the jaw muscles after chewing for some time (jaw claudication)
the pain becomes worse if the patient lies down
the pain also becomes worse if the patient bends down
the patient also suffers from muscle pain elsewhere
the pain is accompanied by a visual disturbance
the patient is older than 50,

You should carry out the following examination:

Palpate the temporal arteries and assess whether the temporal artery on the painful side is tender to palpation, thickened, hard and bumpy.
Assess whether the pulsations on this side are not palpable or palpable to a lesser extent.
Measure the patient’s vision, as other arteries (in particular the retinal arteries) are often also affected, which can lead to visual disturbances.
Determine the erythrocyte sedimentation rate (ESR). The ESR is almost always highly elevated with temporal arteritis (> 40 mm).

Tension headache
7. If you suspect tension headache because

the pain is constantly present
the pain radiates from the neck to the forehead
the pain seems to sit around the head like a tight band
the pain occurs after or during tension or emotions
the pain occurs after reading or watching television for a long time
the pain depends on the patient’s position (lying down in a relaxed manner can, for example, ease the pain)

You should carry out the following examination:

Press your thumb and index finger firmly on the occiput at the point where the trapezius muscle attaches [Figure 117].
Enquire whether this hurts.
Next apply equal pressure with the thumb and index finger to the mastoid process, left and right [Figure 118].
Enquire whether this hurts more. With headaches caused by muscle tension, this should not be the case. Pressure at the trapezius muscle point of attachment is more painful.
Determine the visual acuity. A non-corrected refractive error can cause a tension headache.

Figure 117

Figure 118

Malignant hypertension
8. If you suspect malignant hypertension because

the pain is continually present
the pain is felt in the entire head
the nature of the pain is pounding
the pain is accompanied by nausea and vomiting
the patient is known to have high blood pressure,

You should carry out the following examination:

Measure the blood pressure.

If you find a diastolic pressure below 100 mmHg during the headache episode, you should search for a different cause.

Glaucoma
9. If you suspect glaucoma because

the pain is localised in or around the eye
the pain is accompanied by visual disorders (blurry vision)
the pain is associated with vomiting,

You should carry out the following examination:

measure the visual acuity
examine the anterior eye segment (depth of anterior chamber, pupillary width)
examine the intraocular pressure. For the correct technique you are referred to the book entitled ‘The Examination of the Eye and Vision’ from this series.

Sinusitis
10. If you suspect sinusitis because

the pain is located around one of the sinuses
the pain worsens upon bending over
the pain is accompanied by fever
the pain is accompanied by rhinitis,

You should carry out the following examination:

percuss and palpate the sinus.
assess whether this aggravates the patient’s pain.

Temporomandibular syndrome (Costen’s syndrome)
11. If you suspect temporomandibular syndrome because

the pain is located in or just in front of the ear
the pain becomes worse upon chewing,

You should carry out the following examination:

palpate the patient’s temporomandibular joint while the patient opens and closes their mouth.
inquire whether this is painful.
NB: do not palpate too firmly as this will always be painful.
assess whether there is poor teeth occlusion.

It is not always as easy to establish a diagnosis as may be suggested by the preceding text.
Although it is not difficult to recognise arachnoidal haemorrhage in a patient whose headache started with a sudden bang and in whom the meningeal irritation tests are all positive, or to identify glaucoma in a patient with sky-high intraocular pressure, the signs are not always this clear. A thorough understanding of the above-mentioned diseases and syndromes is therefore essential.