(Cathy) Hi, welcome to Harrison's Podclass where we discuss important concepts in Internal Medicine. I'm Cathy Handy... (Charlie) I'm Charlie Wiener, and we're coming to you from The Johns Hopkins School of Medicine.
A 60-Year-Old with Headache (Charlie) Cathy, one of the hardest topics for clinicians to balance the common with the worrisome is a patient presenting with headache. Today's question highlights some aspects of the history that may help clinicians make this distinction. The question reads, "In a 60-year-old patient complaining of headache, which of the following aspects of the history is worrisome and suggests the need for further evaluation?" Option A is, "First severe headache."
Option B is, "Onset after age 55." Option C is, "Pain associated with local tenderness." Option D is, "Subacute worsening over days or weeks." And, option E is, "All of the above are true." (Cathy) Well, like you mentioned, Charlie, headache is a common concern and most of the time headaches aren't worrisome. But it is important for internists to remember that there are certain signs or symptoms that should heighten one's concern that a more serious problem may be present.
For example, you mention in option A, a patient who presents with a new severe headache has a differential diagnosis that's quite different from the patient who presents with recurrent headaches over many years. In a new onset and severe headache, the probability of finding a potentially serious cause is considerably greater than in recurrent headache. And this is one example that definitely warrants further evaluation. (Charlie) In those kinds of cases, what kind of causes do you think about?
(Cathy) So I think mostly about meningitis, especially if there was fever or nuchal rigidity, subarachnoid hemorrhage or epidural or subdural hemorrhage. Glaucoma I would think about too if there were ocular symptoms and then also purulent sinusitis. The first step is always a careful neurologic examination. (Charlie) What about some of the other choices?
(Cathy) Option B mentions the onset after age 55, and that's also concerning because these patients are at high risk for dangerous causes of headache like hemorrhage and that's mostly due to a higher burden of risk factors like hypertension. Option C, pain associated with local tenderness, makes me think of giant cell arteritis. This is more common in elderly people and is really dangerous because if untreated can lead to blindness due to involvement of the ophthalmic artery and its branches.
You definitely don't want to miss this, because treatment with glucocorticoids is effective in preventing this complication if caught early. Finally, Option D, if a headache continues to get worse, it should also prompt further evaluation. The common benign causes of headache you wouldn't expect to last that long and you wouldn't expect it to worsen during that time period. (Charlie) So, in terms of evaluating these cases, how does imaging with CT or MRI help?
(Cathy) In most cases, patients with an abnormal neuro exam or with a history of recent onset headaches, should be evaluated with a radiology test quickly and usually CT or MRI are the ones that are used. CT is usually the most accessible study to obtain first and quickly. As an initial screening test, CT and MRI are about equally sensitive, but it's really helpful to discuss the clinical scenario and what your concerns are, with your radiologist to ensure that you're ordering the correct study.
For example, if there is suspicion of hemorrhage, a CT is preferred, whereas if the concern is something more subtle, such as multiple sclerosis, an MRI is going to be a better test.
(Charlie) Are there any symptoms that suggest a more serious rather than a benign cause of headache other than the ones (Cathy) So other symptoms that would worry me any pain that's induced by bending, lying down, or coughing, if there's pain that disturbs sleep or presents immediately upon wakening, and certainly if there's known systemic illness such as cancer or if the patient is immunosuppressed for other reasons.
If there's fever or unexplained And, of course, if there are any abnormalities I would definitely be worried and would want to do further testing. (Charlie) So, before we finish, let's just go back to the issue of brain tumors, since that's often patients' biggest concern and what they will come and ask about when they come to clinic. (Cathy) So you definitely can hear that. But fortunately brain tumors are a rare cause of headaches and they are very uncommon to cause severe pain.
(Charlie) So therefore the answer to this question is "E." All of the above that I mentioned before are signs or symptoms that are worrisome for a possible severe cause of headache and merit further evaluation. The teaching point is that the history will often guide you towards distinguishing between a serious or a more benign and furthermore, collaboration with your radiologist can also help guide your evaluation and your diagnostic workup.
(Cathy) For more information about the differential diagnosis of headache, check out the Harrison's chapter on cardinal manifestations and presentation of disease.