Tenderness over the temporal artery Possible sources of headache include polymyalgia rheumatica and temporal arteritis. Worsening pattern of headaches (more intense, more frequent) Worsening headache can be the only sign of serious underlying pathology (Do et al., 2019). In a series of 17 cases of cerebral venous 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 horizontally 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 toxoplasmosis, 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 frequent). ● 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. by (de Coo et al., 2019) looked at the correlation between illicit drug use and cluster headaches. They found that people with cluster headaches 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 prescription and over-the-counter medications can increase the risk of intracranial bleeding. These include aspirin, other nonsteroidal anti-inflammatory drugs, anticoagulants, and
Case Study: Mary Miller Ms. Miller is a 66-year-old female who resides in an assisted living facility. She presents to the outpatient clinic in the facility per referral from the house nurse practitioner for evaluation and treatment of new onset headache. She states the headache started a few days ago. She states she also has been more tired and achy lately, but she attributes this to “old age.” Questions What two red flags are present in this case? What is a possible explanation for her symptoms? Discussion The first red flag for this case study is new onset of headache in a person older than 50 years of age. New onset headaches are 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 diagnosed with primary brain tumors, 38% presented with papilledema and 31% had a triad of headache, vomiting, and papilledema (Do et al., 2019). Other possible sources include mass lesion, encephalitis, meningitis, or pseudotumor. Rapid onset of headache with strenuous exercise Possible sources of rapid onset of headache with strenuous exercise 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. Possible sources include bleeding in a mass or arteriovenous malformation, 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. b. Tension and stress. c. Medication overuse. d. Head and neck trauma. Medical history and headaches Given the long list of possible systemic headache origins, a thorough 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 explaining why you need to know can be helpful. A study
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