a good example of how important it is to be thorough in the medical screening part of patient evaluation. If a thorough review of medications had not been done, it would have been easy to jump to the conclusion that the neck pain was related to the car crash. Case Study: Ms. Jennifer Jones Ms. Jones is seven months pregnant. She is being seen in the physical therapy clinic for treatment of sacroiliac pain. Upon arriving for her second visit, Ms. Jones reports that she has a terrible headache that came on suddenly last night. She is hoping that the physical therapist might be able to address her headache at this clinic visit. Question What condition should Ms. Jones’s physical therapist be worried about? What other symptoms should they question her about, and what test should they complete? Discussion About 5% of pregnancies are affected by preeclampsia and eclampsia. The headache associated with this condition is progressive bilateral (temporal, frontal, occipital, or diffuse), pulsating, and aggravated by physical activity; in addition, it fails to respond to over-the-counter remedies. Other symptoms the therapist should inquire about include changes in vision, shortness of breath, increased swelling, and nausea and vomiting. A very important test that should be completed is assessment of blood pressure, as hypertension is a hallmark of this condition. odontoideum, subdural hematoma, brain metastases, acute sphenoid sinusitis, cerebrospinal fluid–related issues, infection, and vascular diseases (Do et al., 2019). Headache with change in personality, mental status, or level of consciousness A headache that is accompanied by changes in personality, mental status, or level of consciousness is an indication of central nervous system involvement. Possible sources include central nervous system infection, intracerebral bleed, or mass lesion. Neck stiffness or menigismus A headache accompanied by neck stiffness, especially with fever, may indicate encephalitis or meningitis. New onset of severe headache in pregnancy or postpartum Physiological changes associated with pregnancy such as hypercoagulability or hormonal changes, or interventions such as epidural anesthesia create an increased risk for secondary headache. The incidence of new onset headache during pregnancy is estimated to be 5% of all pregnant women, with the highest occurrence in the third trimester (Do et al., 2019). The absence of a headache history and the presence of seizures, hypertension, or fever are additional risk factors that should prompt a more thorough investigation. Half of headache cases in this situation are due to hypertensive disorders (Do et al., 2019). Other possible sources of secondary headache in pregnant women include cortical vein/cranial sinus thrombosis, carotid artery dissection, and pituitary apoplexy. Older than 50 years of age Headaches are less common in older people than in younger people (Togha, 2022). According to Do et al. (2019), older headache patients, especially those who are over 65 years of age, have a higher frequency of serious secondary cause than do younger patients. Per Do et al. (2019), infection is the most common cause of secondary headache in this group. By contrast, Togha et al. (2022) state that medication overuse and trauma to the head and/or neck are the most common causes. Other possible secondary causes include stroke, temporal arteritis, and mass lesion (Do et al., 2019).
Case Study: Mr. George Hall Mr. Hall is a 50-year-old male who presents to physical therapy with new onset of headache. He was involved in a motor vehicle crash three months ago, where he sustained a whiplash injury as well as fractures to his ribs and pelvis. Because of his injuries, he has not been able to work in the construction trade and states that since his accident he has been down and depressed. The headache began two weeks ago, and his physician feels it is a consequence of the whiplash injury from the car accident. In reviewing the client’s medications, the therapist notices that Mr. Hall was prescribed an antidepressant to help him with the depression he has been experiencing since the accident. Question How might the evaluating therapist determine if the headache is related to the new medication? Discussion Many medications, including antidepressants, have headache as a possible side effect. The therapist should question Mr. Hall further to see if the headache onset correlates with starting the new medication. Furthermore, the clinician should complete a thorough physical examination to determine if there are neuromuscular issues that might be causing the patient’s headache, such as upper cervical spine dysfunction or muscle tension. If there are no neuromuscular issues to explain the headache and if headache onset correlates with starting the new medication, the therapist should consult with the prescribing physician to discuss the possibility that the headaches are being caused by the antidepressant Mr. Hall is taking. This case is Headache red flags Remember that red flags are warnings that features of the client’s medical history or clinical examination are associated with a high risk of serious disorders. There are many red flags associated with headaches. When they are present, a referral to another healthcare provider might be warranted as a means for further investigation into the source of your patient’s headache. First or worst headache of the patient’s life A severe headache that reaches maximal intensity within seconds to a minute is associated with numerous underlying disorders. These disorders include subarachnoid hemorrhage, unruptured intracranial aneurysm, cervical artery dissection, cerebral venous sinus thrombosis, stroke, intracranial hemorrhage, reversible cerebral vasoconstriction syndrome, and reversible posterior leukoencephalopathy. This type of headache is approached as a neurologic emergency (Ju et al., 2010). Focal neurologic signs A focal neurologic sign can affect both motor and sensory function. Motor or movement changes include paralysis; weakness; loss of muscle control; increased muscle tone; loss of muscle tone; or movements a person cannot control, such as involuntary movements/tremor. Sensory changes include sensation changes such as paresthesia or numbness (Focal Neurologic Deficits, n.d.). Possible sources include arteriovenous malformation, collagen vascular disease, stroke, or intracranial mass lesion. According to Do et al. (2019), the most common cause of neurologic deficit with headache is migraine with aura, so this should also be considered. Headache occurs in one- fourth of episodes of acute stroke, with a higher frequency in hemorrhagic than in ischemic stroke (Do et al., 2019). Headache triggered by cough or exertion It is thought that coughing raises the pressure in the chest and abdomen, which in turn increases the pressure in the brain ( Primary Cough Headache: Symptoms, Causes, Tests and Treatment, n.d.). Secondary cough headache is associated with Chiari malformation type 1 (a herniation of the cerebellar tonsils; Do et al., 2019). The other diagnosis associated with cough headaches is posterior fossa lesions. Less common possibilities include arachnoid cysts, dermoid tumors, meningiomas, os
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