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Headache Approach: Identifying Life-threatening Conditions and Management

Headache Approach: Identifying Life-threatening Conditions and Management

When evaluating headaches, it's crucial to differentiate between primary and secondary headaches. Primary headaches are functional issues that, while painful, are not immediately dangerous. Secondary headaches, however, are caused by identifiable physical conditions that could be life-threatening. The differentiation can be guided using the "SNOOP4" mnemonic for Red Flag Signs:

  • S: Systemic symptoms like fever, neck stiffness (suggesting meningitis), vomiting (suggesting increased intracranial pressure, IICP), weight loss, fatigue, history of cancer (suggesting brain metastasis), or HIV (suggesting opportunistic infections like Cryptococcal meningitis or Toxoplasmosis).

  • N: Neurologic symptoms such as confusion, weakness, numbness, dizziness, vertigo, or seizures.

  • O: Onset that is sudden or abrupt, including thunderclap headaches (suggesting subarachnoid hemorrhage, SAH) or split-second onset (suggesting arteriovenous malformation, AVM, intracranial hemorrhage, or dissection).

  • O: Older age, typically new onset after 50 years (important for diseases like giant cell arteritis in addition to other pathologies).

  • P: Previous headache history, noting changes in characteristics, frequency, and severity. Worsening conditions suggest a secondary cause.

  • P: Precipitating factors like Valsalva maneuvers (suggesting IICP), exercise or sexual intercourse (suggesting SAH or dissection), and pregnancy (suggesting cerebral venous sinus thrombosis, CVST).

  • P: Positional aggravation, especially when related to lying down or awakening headaches (suggesting IICP).

  • P: Papilledema, which suggests increased intracranial pressure and is a critical finding warranting immediate investigation.

For outpatient cases, to diagnose, ask about additional symptoms such as nausea, vomiting, photophobia, phonophobia, red or tearing eyes, head trauma history, medication use (to exclude medication-overuse headache, MOH), toxin exposure (like CO poisoning), menstrual history, family history, and recent travel (for location-specific infections or opportunistic infections).

Physical Examination:

  • Check vital signs for abnormalities like increased blood pressure and decreased pulse rate, which could indicate Cushing’s reflex due to IICP.

  • Look for tenderness in the temples and neck to rule out giant cell arteritis.

  • Evaluate visual acuity and eye grounds for papilledema in all cases.

  • Listen for carotid and ophthalmic bruits, indicating AVM.

  • Perform a comprehensive neurological examination to identify focal neurological deficits.

Investigation and Management:

  • Investigation varies based on suspected secondary headache causes, including non-contrast CT (NCCT) of the brain for hemorrhages, lumbar puncture (LP) for infections or SAH, CT with contrast or MRI for brain tumors, and CT angiography (CTA) for aneurysms or CVST.

  • Management depends on the underlying cause identified by investigations. For primary headaches, consider supportive treatments to alleviate current symptoms:

  • Migraine: Options include NSAIDs like Ibuprofen (600 – 1,200 mg, then 400 mg every 4-6 hours), Ergotamine (1 tab every 30 min, max 6 tabs/day or 10 tabs/week), and Sumatriptan (50 mg, max 200 mg/day).

  • Tension-Type Headache (TTH): Paracetamol (500 mg, 2 tabs as a single dose) or Ibuprofen (200 – 400 mg as a single dose).

For detailed diagnostic criteria and preventive treatments of primary headaches, refer to standard neurology texts.

This approach emphasizes the importance of not missing life-threatening conditions while managing headaches, ensuring patient safety through thorough assessment and evidence-based management strategies.

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