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Headache Care

Headache - Causes for Concern

Wednesday, Feb 11 2009


The physician should be especially concerned if the patient has any of the following (Silberstein, 1992; Edmeads, 1988): (1) a new-onset headache in a patient over the age of 50; (2) a sudden-onset headache; (3) a headache that is subacute in onset and gets progressively worse over days or weeks; (4) a headache associated with fever, nausea, and vomiting that cannot be explained by a systemic illness; (5) a headache associated with focal neurologic symptoms or signs, such as papilledema, changes in consciousness or cognition (such as difficulty in reading, writing, or thinking), or a stiff neck (other than the typical aura of migraine); (6) no obvious identifiable headache etiology; and (7) a new-onset headache in a patient with cancer or human immunodeficiency virus (Tables 2-7, 2-8).

If a cause for concern exists, neurologic consultation, neuroimaging studies (magnetic resonance imaging or computerized axial tomography), or lumbar puncture may be indicated.

Most patients who see a physician for a headache disorder have an acute exacerbation of a recurrent primary headache disorder or a headache associated with an acute febrile illness. However, all headaches should be taken seriously, and a diagnosis based on the new IHS criteria should be made, prior to instituting treatment if possible.

Successful treatment of a patient with headache often depends on the care and sympathy the physician gives. Cures should not be promised. Patience and perseverance on the part of both physician and patient may be necessary.

image Diagnostic alarms in the evaluation of headache disorders

The physician may find that his or her therapeutic suggestions have not achieved the desired result. It is important, then, not to become angry at the patient. Sometimes simple structuring of the environment will help the patient to modify some of his or her life goals. At times, the patient will demand a type of practical office psychotherapy, an informal program directed toward guidance and re-education of his or her emotional responses.

With careful attention to the whole patient, some resolution of the problem can be achieved in the majority of patients with headache complaints. If the physician suspects a serious thought disorder, psychiatric consultation is mandatory. Headache patients are generally easily treated. Many do not require medical assistance, and those who do usually respond to standard treatments.

image They are anxious to return to their endeavors and aggravated by the annoyance that headache invariably produces. Of course, there are exceptions, e.g., persons with migraine or cluster headache, or even tension-type headache, who need more careful management of their headache problems. Here again, most patients respond to appropriate therapies, and the vast majority can be helped by a knowledgeable physician.

Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.
Edmeads, J. (1988). Emergency management of headache. Headache 28:675-679.
Groves, I.E. (1978). Taking care of the hateful patient. N. Eng. J. Med. 298:883-887.
Headache Classification Committee of the International Headache Society. (1988). Classification and diagnostic criteria for headache disorders, cranial neuralgia, and facial pain. Cephalalgia 8:1-96.
Silberstein, S.D. (1992). Evaluation and emergency treatment of headache. Headache 32:396-407.
Silberstein, S.D. and M.M. Silberstein. (1990). New concepts in the pathogenesis of headache. Part II. Pain Manage. 3:334-342. 

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