Evaluation of Headache
Headache like any other pain usually occurs due to stimulation of nerve endings in response to tissue injury, visceral distension, or other factors. The structure that are involved in headache are the large intracranial vessels and dura mater, the peripheral terminals of the trigeminal nerve that innervate these structures (intracranial vessels and dura mater), the pain modulatory systems in the brain that receive input from trigeminal nociceptors and the caudal portion of the trigeminal nucleus.
The diagnosis of headache is different for a patient who presents with a new severe headache from that of a patient with recurrent headaches over many years. The probability of serious cause of headache is greater with new onset severe headache in compare to old recurrent headache. So, patient with new onset severe headache need careful and prompt evaluation of headache and also prompt treatment. Serious causes of new onset severe headache to be considered are meningitis, subarachnoid hemorrhage, epidural or subdural hematoma, glaucoma, and purulent sinusitis. These causes need to be considered if there are any signs and symptoms that are worrisome. The worrisome signs and symptoms are first time severe headache, “worst” headache ever, headache with fever or unexplained symptoms, vomiting before headache, headache that disturbs sleep or presents immediately upon awakening, worsening of headache over days or weeks, onset of headache after age 55, headache associated with local tenderness, e.g., region of temporal artery; headache induced by bending, lifting, cough and abnormality in neurological examination etc. If any of the above is present with headache prompt treatment is required.
A complete physical and neurological examination is needed as first step of evaluation. If the headache is new onset and there is abnormality in neurological examination CT or MRI studies is needed. A general evaluation of acute headache should include the investigation of cardiovascular status by blood pressure monitoring and renal status by urine examination; eyes by fundoscopy, intraocular pressure measurement, and refraction testing; cranial artery palpation and cervical spine by the effect of passive movement of the head and by imaging.
The psychological status of the patient should be evaluated as there is a relationship between headache and depression. Patient with chronic headache become depressed and sometimes depression may lead to headache. Antidepressant may be required and they are helpful in treatment of both tension-type headache and migraine. Treatment of the headache is usually ineffective until the cause of the primary problem is addressed.
