UNUSUAL HEADACHES - 09/09/11
Résumé |
Headaches represent one of the commonest somatic complaints seen in clinical practice. Between 1.7% and 2.5% of annual emergency department (ED) visits are by patients with a chief complaint of headache.24, 99 It has been estimated that as many as 70% to 90% of the general population will suffer from at least one headache during any given year, with 5% seeking medical attention.83, 90, 94 Economic impact, in terms of lost work days and decreased productivity secondary to headaches, has been estimated at $5.6 to $7.2 billion annually.75
The differential diagnosis of headache is one of the longest in medicine (Table 1). The International Headache Society has classified headache into 13 major categories, with 129 subcategories.45 Primary headache syndromes, including tension and migraine headache, represent the majority of headaches presenting both to primary care physicians and to EDs.24 A study by Edmeads et al demonstrated that 14% of migraine sufferers and 8% of patients with tension headache will present to the ED for treatment at some time during their lives.30
Secondary headaches may be defined as headaches occurring as part of the symptom complex of another condition. Some of these, such as temporomandibular joint headache, are benign, whereas others are associated with significant morbidity and mortality. Secondary headaches occur in as many as 10% of patients seen in the emergency department.76 Dhopesh et al performed a retrospective study of all patients presenting to a large urban ED with the complaint of headache over the period of 1 year.24 The five commonest discharge categories were infection (other than intracranial), tension headache, vascular headache, blood pressure–related headache, and post-traumatic headache. Of the 872 patients, 11 (1.2%) had serious underlying pathology, with 6 of the 11 (55%) being intracranial hemorrhage (ICH). Distinguishing this group with serious underlying pathology from the headache population at large lies at the heart of the difficult challenge that headaches pose to emergency physicians. By definition, the patient presenting to the emergency department represents an a priori high-risk group. The true onus is on the emergency physician not to determine the underlying cause of the headache, but more importantly to exclude clinically significant underlying pathology. Fifty-two (6%) of patients in the study by Dhopesh et al. were discharged from the ED with no diagnosis.24 In reviews of malpractice claims filed against emergency physicians in the state of Massachusetts, misdiagnosed subarachnoid hemorrhage and meningitis were consistently in the high-risk category, accounting for as many as 5% and 2% of all closed cases respectively.57, 58
Numerous chapters and articles have been written concerning the most frequent ominous causes of secondary headache (Table 2).4, 20, 25, 36, 38, 47, 61, 81, 85, 87 Current recommendations mandate a thorough diagnostic evaluation of all patients who present with a “first-or-worst” headache, a progressive subacuteheadache, headache associated with abnormal signs or symptoms (e.g., fever, meningismus, nausea, papilledema, focal neurologic deficits), headaches in HIV-positive patients, or new-onset headaches in patients over the age of 50 years.32 The emergency physician must be attuned to the diagnoses of cerebrovascular disease, subarachnoid hemorrhage (SAH), and bacterial meningitis. The purpose of this article is to aid the clinician by expanding the differential diagnosis of headaches associated with significant morbidity and mortality (Table 2). To this end, seven less common yet equally significant causes of headache are reviewed, with emphasis placed on clinical features and diagnostic studies of choice.
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| Address reprint requests to Edward C. Jauch, MD, MS, Assistant Professor, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH 45267, e-mail: edward.jauch@uc.edu |
Vol 16 - N° 4
P. 741-760 - novembre 1998 Retour au numéro
Article précédent
- ATYPICAL CHEST PAIN
- Nicholas J. Jouriles
- FEVER IN THE IMMUNOCOMPROMISED HOST
- Moss Mendelson
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