APPROACH TO A HEADACHE

Headaches are common. Headaches can kill you. So it’s not a bad idea to have a standardized approach to them. It begins with the history, where you hunt for “red flags.” 

What are “red flags”?

Red Flags are symptoms that suggest danger. They warrant aggressive measures.

• Fever - meningitis, encephalitis or abscess (or it could just be sinusitis)

• Neck Stiffness - meningitis or SAH

• Confusion - encephalitis or CVA

• Focal Neurological Deficit (FND) - stroke, bleed or mass

• Visual Changes - tumors, MS, weird eye pathologies (or just migraines)

• Thunderclap onset - SAH

• Syncope - brain bleed

• Horner’s Syndrome - carotid dissection (or just cluster headaches)

• Change or worsening in a chronic Headache - badness 

• Old age - temporal arteritis or tumor

What if this is their very first headache?

The first headache in a reliable patient warrants a workup. Perhaps refer them to an outpatient neurologist for EEGs and a scan. 

What if there aren’t any red flags?

Then, most likely, this headache won’t kill them. Use clues from the History & Physical to suss out the diagnosis. 

• Aura + Photosensitivity + Nausea = migraine

• Severe u/l eye pain + Horner’s + ANS (Rhinorrhea + Lacrimation + Red Eye) = cluster 

• Just a vague headache = tension

• Fever + nasal congestion + sinus tenderness = sinusitis

Something to keep in mind…

The brain itself is numb, it cannot feel pain. Meninges, cranial nerves, muscles and skin, however, can. 

Also, don’t treat headaches with opioids.