headache+questions+to+ask

=Headache: Questions to Ask=

When dealing with a patient presenting headache, it is important to differentiate between the types of headaches, as well as more sinister conditions. We will be referring to the Questions to Ask - A Headache Profile found [|here]

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Eliminating dangerous conditions
//Ask about the onset of the headache.// - **Sudden onset** with symptoms of confusion, drowsiness, vomiting, or stroke-like referral symptoms (speech loss, numbness, etc) may indicate cerebrovascular causes - immediate referral - **Recent onset** and other symptoms – confusion, drowsiness, fever, neck stiffness, photophobia, vomiting may indicate meningitis, encephalitis, severe hypertension - **Onset after age 50** with either: severe throbbing in temples; joint muscle pain; associated with: bending over, sexual activity, sneezing/coughing, worse lying down? which may indicate a possible brain tumour, temporal arteritis or raised intracranial pressure

General details
//Describe the pain? Sharp? Dull? Location? Duration? Frequency/recurrence?//

- Heaviness, a band-like tightness or feeling of pressure around the head - Non-throbbing, but can worsen to throbbing (mixed tension/migraine type headache) - No aura; nausea and vomiting are unusual - Bilateral
 * Tension headache**: //usually mild and short lived, although they can last up to a week//

- Occurs mainly in men. - Sharp, severe pain, centred around the eye and front of head, on one side. - Often occur at night, waking the sufferer from sleep. - Possible rhinorrhoea, congestion or watery eye on the affected side.
 * Cluster headache**: //shorter duration than migraines, 10 minutes - three hours, up to eight times a day over a period of weeks or months.//

Is it migraine?
//Is there an aura/were there symptoms before the pain started? What were they? Is the headache worsening? Other symptoms with the headache (nausea, vomiting, photophobia, phonophobia)?//

- Unilateral headache - Moderate to severe throbbing pain - Usually photophobia and phonophobia and/or nausea and vomiting.
 * Migraine:** //last from 4-72 hours//

Pain worsens if the person continues routine activity and most sufferers have to stop and rest.

__Aura:__ (found in a third of migraine sufferers) //Lasts up to an hour// - Visual disturbances (shimmering borders, zigzagging forms, loss of vision, lights, spots) - Numbness, pins and needles - Speech disturbances

Is it medication-overuse headache?
//Is headache always present? Is headache often present on waking? Do you take medication daily or nearly every day for headache? Does the headache occur on more than half the days in the month?//

Should be suspected when any acute migraine drugs, including combination analgesics (e.g. Mersyndol or Panadeine), are used 10 or more days per month. A diagnosis of probable medication-overuse headache is also specified if simple analgesics are used 15 or more days per month.
 * Medication-overuse headache**: //also known as rebound headache, drug-induced headache, or medication abuse headache//

Identifying triggers
//Were there any triggers?// //Are you taking any new medications?// //What provides relief? What have you tried to provide relief? What effect is it having on your life?//

- Medications: oestrogen (including combined oral contraceptives), calcium channel blockers, nitrates, NSAIDs (particularly indomethacin), and some erectile dysfunction drugs (sildenafil, tadalafil and vardenafil) - Stress: tightens the muscles of the neck, head, upper back and shoulders. Also lowers the tolerance to pain - Hormone changes: migraine usually occurs in the few days prior to or following a woman's menstrual period - Caffeine withdrawal - Food additives: MSG - Drug use and withdrawal (including analgesics, caffeine, alcohol) - Neck problems, jaw and dental problems, - Eyestrain: Long-sightedness people tend to squint and strain the eye muscles in order to better focus their vision - Blood-pressure problems: including dehydration - Sinus problems, from colds or allergy, can cause chronic headache.
 * Headache**

For many people, migraines are triggered by specific things. These may also trigger nonmigrainous headaches in susceptible people. Some triggers include: - Medications: analgesics (overuse and withdrawal), oral contraceptives, oestrogens, NSAIDs (particularly indomethacin), nitrates, erectile dysfunction agents (sildenafil, tadalafil, vardenafil), calcium channel blockers, proton pump inhibitors, cimetidine, fluoxetine, fenfluramine, nicotine, alcohol, cocaine - Stress - Sensory stimulation – glare, smells - Weather (barometric pressure changes) - Smoke, particularly from cigarettes - Foods including: chocolate, citrus fruit, caffeine (intake or withdrawal), aspartame, food additives (MSG, nitrites, phenylethylamine), tyramine-containing foods (red wine, aged cheeses) - Hormonal changes, menstruation, pregnancy - Strenuous exercise - Inadequate sleep, insomnia - Hypoglycaemia (from lack of food or medication induced).
 * Migraine**

Treatment
//Full list can be found at Headache and Migraine//

Initial treatment is with a simple analgesic – ideally soluble for rapid onset of action. Higher doses are usually used – 600-900mg aspirin or 1-1.5g of paracetamol, four-hourly if required (up to max paracetamol 4g/day).

Simple analgesics (paracetamol, aspirin, ibuprofen) are useful for short-term relief. //Preventive treatment needs to be started as soon as an attack cycle starts//. Subcutaneous sumatriptan may be useful. Withdrawal of the overused agent; this often needs specialist management from a pain or headache clinic. Resolution may take weeks or even months.
 * Tension headache:**
 * Cluster headache:**
 * Medication-overuse headache:**

//Prophylaxis:// - Identifying triggers (keep a diary of attacks) - Propranolol and metoprolol (considered for those who suffer 2-3 migraines a month) //Initial attack:// - Ergotamine 1-2mg is taken at onset of migraine or aura - Triptans are used at the onset of migraine pain (not during aura).
 * Migraine:**

Summary of Questions

 * Eliminating dangerous conditions**: Ask about the onset of the headache
 * General details**: Describe the pain? Sharp? Dull? Location? Duration? Frequency/recurrence?
 * Is it migraine?**: Aura/symptoms before the pain started? What were they? Headache worsening? Other symptoms? (nausea, vomiting, photophobia, phonophobia)?
 * Is it medication-overuse headache?**: Headache always present/upon waking? Do you take medication nearly every day for headache? Headache over half the days of the month?
 * Identifying triggers**: Any triggers? Any new medications? What provides relief? Tried anything for relief? What effect is it having on your life?