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. 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 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). subdural hematoma. Positional headache
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: 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.
b. Tension and stress. c. Medication overuse. d. Head and neck trauma.
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