Investigating and Understanding Headache

Common Pitfalls in the Evaluation and Management of Headache
Headache or head pain occurs due to excess stimulation of nerve endings, as is the case in any other pain. Stimulation of nerves occurs due to tissue injury, distension of viscera including brain or some other factors. In the process of headache, large intracranial vessels and dura matter (both of these structures are supplied by trigeminal nerve) are structures involved. The trigeminal nociceptors send signals to the pain modulatory systems and cause pain (headache).

Headache may be of acute onset (with severe form of headache) or headache may be present for many years which recurs and the diagnosis of two different clinical presentations are different. In general the possibility of serious underlying cause of headache is much more in acute onset severe headache than long duration recurrent mild or moderate headache. That is why patients with acute onset severe headache requires prompt and careful evaluation of headache and quick initiation of appropriate medical therapy.

Some of the causes of acute onset severe headache include meningitis, glaucoma, subarachnoid hemorrhage, epidural or subdural hematoma, and purulent sinusitis. Diagnosis of any of the above should be considered if a patient with acute onset severe headache has “worrisome” symptoms. Worrisome symptoms of headache include vomiting before headache, worst ever headache, first time intolerable severe headache, headache with fever, headache that disturb sleep, headache immediately after awakening in the morning, headache worsen over time (days), headache starts first time after age of 55 years, headache patient with abnormal neurological examination and headache associated with bending, lifting and coughing. A headache patient with “worrisome” symptoms need prompt diagnosis and treatment.

To diagnose cause of headache complete physical and neurological examination is required. Evaluation of headache include general cardiovascular status, routine urine examinations, fundoscopy, cranial artery palpation, IOP (intraocular pressure) measurement, testing for refraction of eyes and imaging investigations such as CT scan and MRI. Headache patient also need complete psychological check up.

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