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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  Signs and Symptoms Series - Headache - Qs to ask « previous next »
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cleo_md
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Signs and Symptoms Series - Headache - Qs to ask
« on: /September/ 30, 2005, 08:46:45 AM »

Ok you are called in the emergency room to evaluate a 45 year old
man who complains of a severe headache that has lasted for several
hours

Who will be the first to suggest which questions to ask yourself and
the patient when you get this call
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musheera
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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #1 on: /June/ 10, 2006, 02:59:16 AM »

I would ask about
Charecter of the headache:
Intensity
Location
radiation
onset
offset
what triggers it

Nausea
Vomiting...projectile??or not

blurred vision

fever

these Q are the 1st that come to ny mind
Plz Dr Nuha Headache is a frequent symptom among  patients ...so I'm waiting for the answers

Fe aman Allah
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princess_ami
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cheer up !!


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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #2 on: /June/ 12, 2006, 02:44:02 PM »

actually i didn't answer because i had a headache  Embarrassed Embarrassed

well i think headach have million cause so we have to ask him about :
-character of headache
-site : frontal , temporal or what ?
-when he has headache? , in morning ......., after hard work , after reading , or it's continuous headache
-is it associated with any other symptoms ? as blurring of vision , vomiting , pain in  ear or teeth  ill ill ...................

general examination checking :
blood pressure ,
 visual acuity ( may be due to error of refraction ) ,
fundus examination ( may reveal increased ICT ) also decreased ICT can cause headache
teeth examination ( dental caries ...........)
ear examination ( otitis media .............. ) or sinusitis ( common cause )
may be constipation or intestinal parasite ( due to toxin )
dehydration or malnutrition
meningitis ( associated with other symptoms )


that's enough for me  Cool Cool



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cleo_md
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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #3 on: /June/ 12, 2006, 02:49:56 PM »

Boy I almost forgot about this question....Ok will give a few more people a chance to answer then will put a good work up for headache Smiley
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3abeer
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Stair way to paradise


Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #4 on: /June/ 13, 2006, 11:36:34 AM »

i would ask also, about the past history, of chronic diseases

visual acquity, dental problems
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princess_ami
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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #5 on: /June/ 16, 2006, 11:02:28 AM »

i forgot to add maigraine ( by history and preceeding and associated symptoms )
and tension headahe

right now i have headache and i don't know its cause  Roll Eyes Roll Eyes
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cleo_md
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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #6 on: /June/ 20, 2006, 06:16:29 PM »

These are all great questions Smiley

Ok so what should we ask ourselves and/or the patietn...


Immediate questions that should come to our mind

1) Has this patient experienced similar headaches before?
If the headache is similar to previous tension or migraine headache then the situation is unlikely to be urgent. However, if the headache is new or deviates from a previous pattern, several potentially serious conditions should be considered., including acute glaucoma, sinusitis, subarachnoid hemorrhage, meningitis, neoplasm and early hyptertensive encephalopathy.

2)What are the patient's vital signs?
Although essential hypertension by itself is an infrequent causes of headache, it may exacerbate preexisting vascular or tension headache. Diastolic blood pressure >140 mm Hgcan cause severe headache. A fever should alert you to the possibility of subarachnoid hemorrhage, meningitis, temporal arteritis or acute sinusitis.

3)Is the patient taking any anticoagulants?
Is there a predisposition to bleeding? Aspirin and warfarin increase the risk of an intracranial hemorrhage, especially with minor head trauma. Spontaneous intracranial bleeding occurs with platelet counts of less than 20,000.


Other Questions:

Location, radiation, severity, alleviating, exacerbating factors?
How often does the patient get headaches?
How long does a typical headache last?
Any pattern to the headaches?
In females, does she notice a relationship between headache and menstrual cycles.
Anything precipitates the headache>
Is the patient under stress?
Any trouble sleeping?
Drug history?
Trauma?
Recent nausea, vomiting, photophobia or visual changes?
Any dizziness? drowsiness? confusion?
Recent seizures? History of seizures?

DIFFERENTIAL DIAGNOSIS


A detailed well focused history is the most important tool for evaluating headache. The great majority of headaches are secondary to either tension-type or migraine headaches. a headachemay also be the only symptom of a more serious condition such as an intracranial mass, temporal arteritis, meningitis and subarachnoid hemorrhage.

(A) TENSION HEADACHE
1- Episodic tension-type headache.

This is frequently described as a squeezing, "band like" tightness that is usually felt bilaterally. IT may occur in the occipital, frontal or bitemporal regions. Occasionally, patients with tension-type headache may describe a " throbbing" pain. This form of headache may last minutes to days; it is generally described as having a mild to moderate intensity.

2-Chronic tension-type headache.

This headache is similar to the acute tension-type in quality but its duration may be months to even years. Depression, personality problems, and a history of narcotic abuse are common in these patients.

(B) MIGRAINE HEADACHES

Although the precise pathophysiology has not been full ascertained , it is though to be secondary to cerebral vasoconstriction followed by vasodilation. The initial vasoconstriction may be associated with a variety of neurological deficits including visual disturbances( scotomas, zig-zag lines, bright lights), dysarthria, hemiparesis and hemianestheisa. Of these, the visual phenomena are most common. These neurologic features generally last 5-30 mins and are then followed by headache. The headache is usually pounding or throbbing but may be dull and boring. It is usually unilateral but may all occur bilaterally in any location.
The attack my last several hours to 2-3 days and occasionally longer. Migraines are much more common in women. Three characteristic migraine patterns are recognized:

1-Migraine without aura ( common migraine)
This vascular headache is not preceded by neurologic deficits or visual disturbances. It is the most comon type, especially in women.

2- Migraine with aura ( classic migraine)
THe headache is preceded by visual deficits such as scotomas and field deficits, but can affect somatic sensation, speech and motor function.

3-Complicated migraine.
The headache is accompanied by neurological symptoms including hemiplegia and ophthalmoplegia.


(C) CLUSTER HEADACHES
Cluster headaches are excruciating, usually unilateral and frequently associated with ipsilateral nasal congestion, lacrimation, and conjunctival injection. Nausae, vomiting, photophobia typically lasts < 2 hours; however, multiple attacks can occur within 24 hour period.
Onset shortly after falling asleep is common. Unlike migraines, cluster headaches most often affect men between the agres of 20 and 40 . They are not familial.

(D)TEMPORAL ARTERITIS
Temporal arteritis should be considered in any patient older than 50 years presenting with a recent history of headache. Other symptoms such as malaise, weight loss, fever and myalgias are frequenlty present. Jaw claudication is a classic symptom. It is especially important to ask about any new visual problems such as double or blurred vision. Temporal arteritis can cause sudden blindness as a result of infammation of the ophthalmic artery. Early diagnosis and treatment with steroids are necessary to prevent this complication.

(E)TRIGEMINAL NEURALGIA

This condition is more common in the elderly. The pain is described as brief, but severeand jabbing. The pain is usually unilateral and localized to one or more division of the trigeminal nerve. Precipitants including talking, chewing, or having physical pressure exerted on a specific trigger area. Etiology is unknown.

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cleo_md
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Re: Signs and Symptoms Series - Headache - Qs to ask
« Reply #7 on: /June/ 20, 2006, 06:46:16 PM »

(F) CEREBROVASCULAR DISEASE

Headache can be a presenting complaint in some patients experiencing an acute stroke. When the internal carotid is involved, the headache is usually located in the frontal region; involvement of the vertebrobasilar system generally yields an occipital headache. The headache of a cerebrovascular accident may precede or follow focal neurological symptoms.

(G)SINUSITIS
Headache is usually dull, aching and located frontally. Pain is frequently worse int he morning when the patient awakens but improves as the sinuses drain during the day. If the patient displays an altered mental status or complains of a stiff neck, a complicated sinus infection should be suspected ( brain abscess, meningitis, septic cavernous thrombosis)

(H)EYE DISEASE

Glaucoma, keratitis and uveitis may cause headaches. The pain is usually dull and located in the periorbital or retroorbital regions.

(I) DENTAL DISEASE

The teeth are innervated by the second and third divisions of the trigeminal nerve; thus, disease involving these structures may cause pain referred to the face or head. Secondary muscle spasm may result.

(J)TEMPOROMANDIBULAR JOINT DISEASE
Headache is usually unilateral on the side of face and head. It is described as " aching" in quality and is worsened with jaw movement.

(K) MASS LESIONS
Both neoplasm and brain abscess can produce headache as a result of either increased pressure or distension of local structures. Any new neuralgic deficit such as visual of motor loss or change in mental status should alert you to the possibility of a mass lesion.
Ones of new headache in a patient greater than 50 years suggests a mass lesion. Non specific features of headache resulting from a mass lesion included progressive worsening headache despite administration of analgesics; early- morning headache ; headache exacerbated by coughing or sneezing; anorexia; and vomiting without nausea. It is important to note that these features also occur frequently with other types of headache , including chronic tension headache, migraine headache, cluster headache and sinus headache.

(L) SUBARACHNOID HEMORRHAGE
The rupture of a cerebral aneurysm is associated with acute onset of a violent headache. The typical patient with a SAH has a sudden onset of severe headache ( frequently described as the worse headache of his/her life) that develops during exertion. Transient loss of consciousness, buckling of the legs often accompanies the headache. Vomiting soon follows.
Between 20-50% of patients with documented SAH report distinct , unusually severe headache int he days or weekd before the index episode of bleeding, referred to as " warning headache"
These so called " thunderclap" headaches develop in seconds,achieve maximal intensity in minutes, and last hours to days.

The differential diagnosis include SAH, dissection or thrombosis or unruptured aneurysms, cerebral venous sinus thrombosis, brief headaches during exertion and sexual intercourse, ..etc

(M)CAROTID OR VERTEBRAL ARTERY DISSECTION
Unilateral head, face or neck pain and a partial Horner syndrome ( miosis, ptosis with out anhidrosis) with subsequent retinal or cerebral ischemia is the classic presentation of carotid artery dissection. The headache may be similar to the headache associated with SAH ( thunderclap headache) but the onset is usually insidious. Unilateral facial or orbital pain is common. Transient ischemic attacks or trasient monocular blindness occurs hours to days after the onset of the pain. An occipital headache or neck pain followed by unilateral arm pain or weakness suggests vertebral arterial dissection.

(N)ACUTE FEBRILE ILLNESS
Fever may cause a vascular- type throbbing headache that remits as the illness resolves. Any febrile patient in whom headache is a major complaint should also be suspected of having meningitis, especially if nuchal rigidity or other signs of meningeal irritation are present.

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