When to worry about headache

Headache related to brain tumors

Headache is one of the most common somatic complaints of patients seeking medical care. Most headaches are not of serious cause and can be diagnosed easily with a good history and physical examination. The challenges to the physician are to determine when underlying intracranial pathology may be causing the symptoms and signs, and to identify the few patients in whom a tumor is the cause of the headache. The subject of headache in patients with brain tumors has been reviewed in neurologic textbooks and in several investigations before, as well as after, modern imaging diagnostic techniques became available. Headache can also manifest as an acute or chronic complication of radiation treatment and/or chemotherapy in patients with intracranial neoplasm, but there are few data in the literature specifically addressing this subject. This article provides an overview of headache in patients with primary and secondary brain tumor, including headache characteristics, the putative mechanism for these headaches, the role of diagnostic testing, and the general principles of management.

Red flags in patients presenting with headache: clinical indications for neuroimaging

Headache is a very common patient complaint but secondary causes for headache are unusual. Neuroimaging is both expensive and has a low yield in this group. Most patients with intracranial pathology have clinical features that would raise a "red flag". Appropriate selection of patients with headache for neuroimaging to look for secondary causes is very important. Red flags act as screening tools to help in identifying those patients presenting with headache who would benefit from prompt neuroimaging, and may increase the yield. The aim of this study is to evaluate clinical features in patients with headache using neuroimaging as a screening tool for intracranial pathology. 20 red flags were defined. A retrospective study of 111 patients was performed and the outcomes were divided into positive and negative. Abnormal neuroimaging was present in 39 patients. Results were analysed using the Logistic Regression model. Sensitivity and specificity of red flags were analysed to establish the cut-off point to predict abnormal neuroimaging and a receiver operating characteristic (ROC) curve plotted to show the sensitivity of the diagnostic test. Three red flag features proved to be statistically significant with the p-value of less than 0.05 on both univariate and multivariate analysis. These were: paralysis; papilloedema; and "drowsiness, confusion, memory impairment and loss of consciousness". In addition, if three or more red flags from the list were present, this showed strong indication of abnormal neuroimaging, from cut-off point of ROC curve (area under the curve =0.76).

Brain tumors

The total care of a patient with an incurable brain tumor is a complex task. It is best performed by a team of specialized care providers including neurologists, neuro-oncologists, neurosurgeons, radiation oncologists, nurses, neuropsychologists, social workers, and physical and occupational therapists. Hospice providers, and spiritual counselors provide particular skilled services and comfort to patients nearing the end of life. The role and prominence of each team member evolves during the course of the illness as the disease progresses and the symptoms and needs of the patient change. Family members often provide the bulk of the direct care, and themselves require support, education, and counseling. While we currently lack curative therapies for most patients with malignant brain tumors, careful attention to symptom diagnosis and management can greatly enhance the quality of life of a patient with a brain tumor throughout the course of the illness and at the end of life.

The management of acute headache in adults in an acute admissions unit

There have been no previously published studies about acute admissions with headaches to a medical admissions ward. In our retrospective case-note study of all patients admitted with headaches to the acute medical admission ward of Ninewells Hospital, Dundee over a six-month period, there were 114 admissions with headache (2.4% of all admissions). CT scans were done in 68 (59.6%) and were abnormal in 21 patients. Twenty four patients (21.1%) had serious underlying causes for headaches. Predictors for CT abnormalities are discussed. Eighteen patients had lumbar punctures and six had abnormal results. Most patients were discharged after one day, nine were transferred to the neurosurgical unit and there were two deaths. Deficiencies in record keeping were identified as was a lack of precision in diagnosis. Changes in practice are needed to improve patient care and perhaps national guidelines are required.

Unusual headaches

Headache represents one of the most common somatic complaints seen in the emergency department, accounting for 1% to 3% of all emergency department visits. Although most headaches seen in the emergency department are benign, as many as 10% of all headaches are secondary to an underlying pathologic condition. The emergency physician is well-trained to exclude stoke, subarachnoid hemorrhage, and meningitis as potential causes of headache. This article focuses on seven unusual headache syndromes, all of which are associated with significant morbidity and mortality. Particular emphasis is placed on clinical features and diagnostic modalities of choice.

Headache in the emergency department: importance of history in identifying secondary etiologies

Headache is a common emergency department complaint and has a broad differential diagnosis. Most commonly the headache is without serious underlying cause, but occasionally can be the manifestation of a more catastrophic illness. History may be the most important aspect in the evaluation of headache patients and careful attention to historical clues or atypical symptoms may point to a diagnosis. We present a patient with a first-time headache, which was ultimately found to be secondary to a carotid cavernous fistula. Historical features that require a more aggressive work-up of headache are discussed.

Computed tomography in the emergency department

A study was conducted to determine parameters indicating the current use of computed tomography (CT) in the emergency department (ED). Computerized data regarding patients seen in the ED between 1/1/92 and 9/30/95 were retrieved. A rate of 36/1,000 patients underwent CT in the ED (ED CT). Of patients eventually hospitalized, 6.04% had ED CT, whereas 2.81% of the discharged patients had undergone ED CT (P < .001). The most common region examined by ED CT was the head (55.38%), followed by the abdomen (14.19%), pelvis (11.96%), spine (11.46%), and chest (5.57%). The hospitalization rates for patients undergoing head and spine ED CT were 35.99% and 36.84%, respectively. The hospitalization rates for patients undergoing abdomen, pelvis, and chest ED CT were 50.76%, 51.46%, and 55.61%, respectively. The mean number of patients undergoing ED CT increased according to age with a positive linear correlation. Head CT was most common in the very young and the very old. Some parameters about the use of ED CT were identified. The information obtained will allow comparison of practice between EDs in different medical centers and will be useful to hospital administrators, health planners, and clinicians. This retrospective analysis is to be followed by more comprehensive prospective studies involving different EDs in various sections of the country.