● Change in personality, mental status, or level of consciousness that accompanies the headache and that may indicate a central nervous system infection, an intracerebral bleed, or a mass lesion. ● Tenderness over the temporal artery , which may indicate polymyalgia rheumatica or temporal arteritis. ● Contusion or lacerations on the face or scalp , which may indicate trauma to the head with resultant cranial bleed. Headache pain pattern During the interview at the initial evaluation, it is important to ascertain very specific details about the nature of the patient’s headache. This includes asking about the onset of headaches; if the headaches are constant or intermittent; and if intermittent, how frequently the headaches are present and what makes them worse or better. Outlined below are some specific details about the connection between headache pain pattern and potential red flags: ● Sudden onset of headache pain with maximal intensity occurring within seconds to minutes, which is called a thunderclap headache ; these headaches require immediate attention and are most often seen in the emergency department; this pain pattern can indicate Summary In summary, here is a concise list of headache red flags related to medical history, clinical presentation, and pain pattern. Summary headache red flags: Medical history ● History of cancer, HIV, or Lyme disease. ● Illicit drug use. ● Use of certain medications. ● Trauma to the head (fall, motor vehicle crash). ● Pregnant or postpartum. ● Recent fever. ● Age over 50 years. ● Accompanying rash or fever. including chronic headache pain, is complex and involves contributions from neurophysiological, neurobiological, cognitive, and sociological systems. Pain neuroscience education (PNE) involves addressing a patient’s misconceptions about the physiological phenomena of pain and providing education on the biological, psychological, and social processes that contribute to experiencing pain (Robins et al., 2016). The biopsychosocial model has emerged as the predominant explanation for the pain experience, especially chronic pain. This perspective considers the psychological, social, and contextual factors that combine with biological influences to contribute to the experience, maintenance, and exacerbation of pain symptoms (Adams et al., 2015). This model is an advancement on the previous one, which is often how our patients understand their pain, believing that the experience of pain is in direct proportion to the degree of tissue strain/stress and that alleviation of symptoms should center on addressing that tissue damage. Psychological factors that have been shown to influence the experience of pain include depression, anxiety, posttraumatic stress disorder, and substance misuse and dependence (Adams et al., 2015). Cognitive and affective features that have been shown to contribute
Self-Assessment Quiz Question #15 Tenderness over the temporal artery as a source of headache may be an indication of two different headache red flag diagnoses. These include: a. Polymyalgia rheumatica and temporal arteritis. b. Rheumatoid arthritis and temporal arteritis. c. Temporal arteritis and polymyalgia rheumatica. d. Intracranial bleed and papilledema. bleeding into a mass or arteriovenous malformation, mass lesion, or subarachnoid hemorrhage. ● A description by the patient of the headache being the first or worst headache of their life, which may indicate a central nervous system infection or an intracranial hemorrhage. ● Headache that is triggered by coughing or with exertion or while engaged in sexual intercourse, which may indicate a mass lesion or subarachnoid hemorrhage. ● Rapid onset of headaches with strenuous exercise , which may indicate carotid artery dissection or intracranial bleed. ● Worsening pattern of headache which may indicate a history of medication overuse or the presence of a mass lesion or subdural hematoma. Summary headache red flags: Clinical presentation ● Neurologic abnormalities. ● Very high blood pressure. ● Vision changes. ● Personality or mental status changes. ● Tenderness over the temporal artery. ● Facial contusion or laceration. Summary headache red flags: Pain pattern ● Sudden onset of headache with maximal intensity reached within minutes or seconds. ● First or worst headache of a patient’s life. ● Headache triggered by cough, exertion, or strenuous exercise. ● Worsening pattern of headaches. to the experience of pain include anger, the patient’s interpretation of their situation (“This pain means something is terribly wrong”), catastrophic thinking and fear avoidance, hypervigilance, perceived helplessness, self-efficacy, and psychological inflexibility. Social factors associated with the experience of pain include social learning, social stigma and skepticism, and social support (Adams et al., 2015). A critical part of the biopsychosocial pain model and of pain neuroscience education is the concept of central sensitization. Central sensitization involves changes in the central nervous system that lead to pain hypersensitivity and the potentiation of chronic pain (Latremoliere et al., 2009). Central sensitization enhances the sensory response to normal inputs, including those sensations that would usually not cause pain (Latremoliere et al., 2009). Several explanations have been offered for the development of central sensitization. These include dysregulation in both ascending and descending central nervous system pathways due to physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system as a result of physical trauma or viral infection (Mayer et al., 2012). Another possible explanation is dysfunction of the stress system, including the hypothalamic–pituitary–adrenal axis (Mayer et al., 2012).
Central sensitization in the differential diagnosis of headaches The pathogenesis and perpetuation of chronic pain,
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