Headache
Q1: List common clinical conditions where symptomatic headache is due to serious intracranial disease?
- Acute Onset
- Subarachnoid hemorrhage
- Other cerebrovascular diseases
- Meningitis/encephalitis
- Subacute Onset
- Intracranial mass (tumor, subdural hematoma, abscess)
Q2: Imaging studies are not required for most of the patients presenting with headaches. List conditions where imaging studies are useful for determining the etiology of headache?
- “Worst headache of my life”
- H/A s/p head trauma
- H/A with h/o fever, malaise, neck stiffness
- Worsening headache associated with weight loss or neurological abnormalities
Q3: What are the available imaging procedures and their utility in the investigation of headache?
- CT and MRI
- In general, there are advantages of each
- CT-quick (minutes), therefore good for the unstable patient
- MRI-better anatomy; can get multiple views
Q4: What are the indications for CT ?
- Progressive neurological disorder
- Focal neurological deficits with suspected structural lesion
- Dementia
- Increased ICP
- CT preferred in suspected stroke within 48 hours to rule out hemorrhage
Q5: What are the indications for MRI ?
- After 48-72 hours, MRI preferred to evaluate for subacute bleed
- CT and MRI useful to detect mass lesions, but MRI preferable for tumors at vertex and in posterior fossa
- MRI better at detecting inflammation and abscess
Case 1:
A 28 year-old female comes to you complaining of a headache on and off during the last month. It is located at the forehead bilaterally and at the back of the upper neck. It is sometimes relieved by Tylenol. Upon further questioning you learn that also during the last month, she and her husband have separated, leaving her home with her two young children, a period of time she describes as “stressful”.
- Are imaging procedures necessary for this patient? If so, what would you order?
- What is your diagnosis?
Two years later, her domestic problems resolved, the same woman comes to your office complaining of another headache of two weeks duration. This time, she describes the pain as located around both of her eyes, her cheeks, and her teeth. She says that when she bends down to pick something up off the floor, the pain worsens. She has also noticed increased nasal congestion and a sore throat that is worse in the morning. She has noticed yellowish-green mucus. She tells you she has been on two courses of antibiotics but the symptoms persist.
- Are imaging procedures necessary for this patient? If so, what would you order?
- What is your diagnosis?
Five years later, our patient, now 35 years old, comes to your office complaining of worsening peripheral vision over the past few months. She also complains of an associated headache that she cannot describe well. Her last menstrual period was 7 weeks ago. Neurological exam shows bitemporal hemianopsia. Her serum beta-HCG is normal.
- Are imaging procedures necessary for this patient? If so, what would you order?
- What is your diagnosis?
Case 2:
A 48-year-old male is rushed to the emergency department by his wife after the sudden onset of the “worst headache” of his life while he was home watching television. The patient began vomiting in the car en route to the hospital. ABCs were assessed and addressed in the ED, and the patient is stable.
- Are imaging procedures necessary for this patient? If so, what would you order?
- What is your diagnosis?