nous thrombosis with headache as the only presenting symptom, 65% had a progressive course of their headache (Do et al., 2019). Other possible sources include history of medication overuse, mass lesion, and subdural hematoma. Positional headache Headache occurring immediately or within seconds of coming to an upright position that resolves quickly upon lying down horizon- tally is suggestive of low cerebrospinal fluid pressure (Do et al., 2019). It is a red flag for intracranial hypotension, which is most often caused by a cerebrospinal fluid leak at the spinal level (Do et al., 2019). Human immunodeficiency virus (HIV) Headache is the most common pain problem associated with HIV (Do et al., 2019); the possible sources of this headache pain include opportunistic infection and tumor (cerebral toxoplasmo- sis, primary central nervous system lymphoma, and progressive multifocal leudoencephalopathy); the risk for severe pathology is related to the degree of immunosuppression (Do et al., 2019). Headache Red Flags ● First or worse headache of a patient’s life. ● Focal neurologic signs. ● Headache made worse by cough or exertion. ● Headache with change in personality, mental status, or level of consciousness. ● Neck stiffness or menigismus. ● New onset of severe headache in pregnancy or postpartum. ● Older than 50 years of age. ● Papilledema. ● Rapid onset of headache with strenuous exercise. ● Sudden onset of headache with maximal intensity. ● Systemic illness with headache (such as fever or rash). ● Tenderness over the temporal artery. ● Worsening pattern of headaches (more intense, more fre- quent). ● New headache type in a patient with cancer, HIV, or Lyme disease. Self-Assessment Quiz Question #13 A woman in the third trimester of pregnancy presents with new onset of headache pain. Which of the following vital signs would be considered abnormal and might indicate the need for immediate medical intervention? a. Blood pressure of 180/120. b. Heart rate of 100. c. Respiration rate of 24. d. Temperature of 99 degrees Fahrenheit. Medication use can also help you understand a client’s medical history, enabling you to link the medications they are taking to the underlying condition they are being used to treat. HIV history As mentioned above, HIV increases the risk of infection and tu- mors. In this case, headache might be the product of a central nervous system infection or an intracranial tumor. Recent infection As mentioned above, a coexisting infection in the lungs, sinuses, or orbital areas may precede and cause a central nervous system infection. Pregnancy or postpartum As mentioned above, pregnancy increases the risk of cortical vein/ sinus thrombosis, carotid artery dissection, and pituitary apoplexy. History of cancer Metastasis should be considered whenever there is a history of cancer. Metastasis to the brain could be a source of headache pain.
less common in older adults than they are in younger people. In addition, when new onset headaches are present, they often are due to a secondary cause. The second red flag is related to the accompanying symptoms of fatigue and muscle aches. Although the client attributes these symptoms to being old, when present with a headache, they may indicate the presence of an infection such as a cold, influenza, or COVID-19. Self-Assessment Quiz Question #12 New onset of headache in persons older than 50 years is less common than in younger persons. Which of the following has NOT been identified as a frequent cause of headaches in those 50 years and older? a. Infection. Papilledema Papilledema (swelling around the optic disk where the optic nerve enters the eyeball) is a predictor of intracranial abnormalities (Do et al., 2019). In a retrospective study of pediatric patients diag- nosed with primary brain tumors, 38% presented with papillede- ma and 31% had a triad of headache, vomiting, and papilledema (Do et al., 2019). Other possible sources include mass lesion, en- cephalitis, meningitis, or pseudotumor. Rapid onset of headache with strenuous exercise Possible sources of rapid onset of headache with strenuous exer- cise include carotid artery dissection and intracranial bleed. Sudden onset Sudden onset headache is also known as a thunderclap headache with maximal headache intensity within seconds to minutes. Pos- sible sources include bleeding in a mass or arteriovenous malfor- mation, mass lesion (especially posterior fossa), or subarachnoid hemorrhage (Thunderclap Headaches - Symptoms and Causes, 2020). Systemic illness with headache (such as fever or rash) Headache with fever is alarming primarily when it is accompanied by symptoms such as neck stiffness, decreased consciousness, and neurologic deficit (Do et al., 2019). Possible sources include arteritis, collagen vascular disease, encephalitis, and meningitis. Tenderness over the temporal artery Possible sources of headache include polymyalgia rheumatica and temporal arteritis. Worsening pattern of headaches (more intense, more frequent) b. Tension and stress. c. Medication overuse. d. Head and neck trauma. Worsening headache can be the only sign of serious underlying pathology (Do et al., 2019). In a series of 17 cases of cerebral ve- Medical history and headaches Given the long list of possible systemic headache origins, a thor- ough review of a patient’s medical history is particularly important in patients with headaches. The following aspects of their medical history deserve special attention. Illicit drug use Using cocaine or methamphetamine causes an increased risk of intracranial bleed. Sometimes patients may be hesitant to tell you about illicit drug use. Asking in a nonjudgmental way while ex- plaining why you need to know can be helpful. A study by (de Coo et al., 2019) looked at the correlation between illicit drug use and cluster headaches. They found that people with cluster head - aches were more likely to have used cannabis, amphetamine, heroin, and cocaine in their lifetime. Medications A review of a patient’s medications is always important. Some pre- scription and over-the-counter medications can increase the risk of intracranial bleeding. These include aspirin, other nonsteroi- dal anti-inflammatory drugs, anticoagulants, and glucocorticoids.
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