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. 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 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 glucocorticoids. 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 tumors. 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.
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.
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. History of Lyme disease Lyme disease increases the risk meningoencephalitis. Age over 50 years Advanced age increases the risk of temporal arteritis and a mass lesion. Fever or rash A recent history of infection increases the risk for arteritis, collagen vascular disease, encephalitis, or meningitis. Onset of headache related to a fall that involved hitting the head A fall increases the risk of intracranial bleed, especially if the client is on blood thinners. Self-Assessment Quiz Question #14 An important part of medical screening is a review of the patient’s medications. Several medications can increase the possibility of an intracranial bleed as a source of headache pain. These medications include: a. Antibiotics and NSAIDs. b. Antibiotics and anticoagulants. c. NSAIDs, anticoagulants, and glucosteroids. d. NSAIDs, antibiotics, and glucosteroids. ● Severe high blood pressure with a systolic pressure greater than 180 mm Hg or diastolic greater than 120 mm Hg; this may signal a central nervous system infection and/or increased intracranial pressure. ● The presence of papilledema , with symptoms involving brief changes to vision such as blurring, double vision, seeing flashes, or vision loss that last a few seconds; this may signal the presence of encephalitis, mass lesion, meningitis, or pseudotumor.
Clinical presentation/physical examination and headaches Specific clinical symptoms and physical examination findings can be considered headache red flags. When present, these symptoms might warrant referral to a medical specialist (Hainer et al., 2013). ● Neurologic abnormalities , particularly in association with acute headache, can be a red flag; these symptoms include unilateral vision loss, meningismus (a group of symptoms similar to meningitis, including headache, reaction to light, and stiff neck (Meningismus – Definition, n.d.), extensor plantar response, and unilateral pronator drift.
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