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Introduction

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When the head aches, all the body is out of tune.

Miguel de Cervantes (1547–1616)

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Headache, one of the cardinal symptoms known to human beings, is a very common complaint in general practice. When a patient presents with ‘headache’ we need to have a sound diagnostic and management strategy as the problem can be confusing. The key to analysing the symptom of headache is to know and understand the cause, for ‘one only sees what they know’.

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The patient’s manner of presentation can confuse us because many tend to influence us with preconceived ideas that they will verbalise—‘I think I need my blood pressure checked’ or ‘My eyes need testing’—or they may not mention their anxiety about a cerebral tumour or an impending stroke.

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Hypertension is such a rare cause of headache that one is tempted to stress the adage ‘hypertension does not cause headache’, but we do encounter the occasional patient whose headache appears to be caused by hypertension and it is mandatory to measure the blood pressure of patients presenting with headache. Patients expect this routine and reassurance is difficult without the appropriate physical examination. Where headaches and hypertension coexist, assume that the headaches are not due to hypertension.

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The diagnosis of serious causes of headache depends on a careful history, a high index of suspicion of the ‘different’ presentations and the judicious use of CT scanning.

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Key facts and checkpoints

  • Eighty-five per cent of the population will have experienced headache within 1 year and 38% of adults will have had a headache within 2 weeks.1

  • Forty per cent of children will have experienced one or more headaches by the age of 7 and 75% by the age of 15.2

  • Headache can be classified as primary or secondary e.g. intracranial pathology, TMJ, cervical spine.

  • Migraine affects at least 10% of the adult population and one-quarter of these patients require medical attention for their attacks at some stage.3 It is under-recognised and poorly managed in the community.4

  • Five per cent of children suffer from migraine by the age of 11 years.3

  • Seventy per cent of sufferers have a positive family history of migraine.

  • Many headaches previously considered to be tension are secondary to disorders of the neck, eyes, teeth, temporomandibular joints or other structures.3

  • Drug-induced headaches are common and must be considered in the history.

  • In children the triad of symptoms—dizziness, headache and vomiting—indicates medulloblastoma of the posterior fossa until proved otherwise.

  • A typical triad of symptoms in an adult with a cerebral tumour (advanced) is headache, vomiting and convulsions.

  • Eye strain is not a common cause.

  • Secondary bronchogenic bronchial carcinoma is the commonest cause of intracerebral malignancy.

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A diagnostic approach

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A summary of the diagnostic strategy model is presented in Table 56.1.

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