Headache

A 24-year-old woman presents to the emergency department (ED) withgeneralized weakness, headache, and muscle cramping that have progressivelyworsened over the past week. Recently, she has also had nauseaand vomiting. She denies chest pain, palpitations, dyspnea, cough, fever,chills, diarrhea, and urinary symptoms. She has a history of type 1 renaltubular acidosis.

TOLEDO, Ohio -- Migraine sufferers often have more than a headache, according to investigators here.

A 47-year-old woman complains ofepisodic headaches that began severalmonths earlier and are accompaniedby sweating, flushing, abdominal pain,and vomiting; these attacks have progressivelyworsened. She takes no medicationsand denies fever, chills, andnight sweats. The medical history isunrevealing.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

A 23-year-old man presents to the emergency department with fever, headache,and photophobia. His illness began 5 days earlier with malaise, followed byfever, prostration, nausea, and vomiting. After 3 days, a severe headache developed,accompanied by photophobia; the headache did not respond to over-thecounteranalgesics.

A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

In the first case study featured in the article by Drs Jagoda and Riggio, “WhatYou Forgot About the Neurologic Exam, Part 1: History, Mental Status,Cranial Nerves” (CONSULTANT, December 2004, page 1773), a 46-year-oldwoman with a history of migraine presented with a bilateral headache thatradiated to the occiput.

A 27-year-old woman is hospitalized after laboratory studies revealed extremelyelevated liver enzyme levels. The studies were ordered after the patient soughtmedical attention for severe headaches that began 3 weeks earlier and for thepast several days had been accompanied by malaise, nausea, and vomiting.

A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides ofthe head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominaldiscomfort and pain. He becomes passive and irritable during the headache; he does not want to be aroundpeople, play, or even watch TV. The patient’s parents note that a few hours before a headache, he becomes somewhatrestless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,location of pain, and associated symptoms) has not changed since that time. The patient’s mother and maternalgrandmother suffer from migraine.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.About 12 years earlier, the patient started having migraine headaches. She had no significant medical history, norwas there any obvious precipitating event. Typically, she had 1 or 2 debilitating headaches a month. These were accompaniedby photophobia, nausea, and vomiting-but not by auras. Oral triptans usually relieved the pain and associatedsymptoms within 1 hour.

Acamprosate calcium (Campral)from Lipha Pharmaceuticals, Inc,has been approved by the FDAfor the treatment of alcohol-dependentpersons who wish to remain alcohol-free after they have stoppeddrinking. Although its mechanismof action is not fully understood,this drug was shown to be more effectivethan placebo in maintainingabstinence. Acamprosate is nonaddictiveand has been shown to bewell tolerated in clinical trials. Themost common adverse effects areheadache, diarrhea, flatulence, andnausea.

A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.

Primary care doctor: Because of the patient’s age and theabsence of a headache history, I first considered such secondarycauses as tumor and temporal arteritis. However,MRI of the brain and erythrocyte sedimentation rate werenormal. I now suspect a sleep-related headache becausethe attacks occur only at night and awaken the patientfrom a sound sleep. How can I determine which type ofsleep-related headache is involved?

For 2 weeks, a 58-year-old woman has experienced increasingfatigue with activity. She has needed to nap duringthe day, has not been able to perform her usual activities,and has missed 3 days of work. She also complains of“muscle aches”-mainly in her back. She denies headache,dyspnea, fever, hot or cold intolerance, and alteredmentation.

Clinician: The patient’s symptom profile is confusing, especiallybecause his test results are normal. Are his amnesicepisodes related to his migraine?

A 32-year-old woman is admitted to the hospital because of nausea, vomiting,and mild jaundice. For 4 days, her health has steadily deteriorated: hepatictransaminase and bilirubin levels are elevated, prothrombin time is prolongedand, most recently, obtundation and changes in mentation have developed.Serologic studies for infection with hepatitis A, B, and C viruses are negative,as are tests for Epstein-Barr virus mononucleosis.

An 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.

Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.

A 60-year-old man has had anterior neck discomfort for the pastseveral weeks. He also has right-sided cephalalgia and occasional jaw discomfortwhile eating but no dysphagia or odynophagia. The cephalalgia, which hasbeen present for the past week, is moderately severe and is associated withblurred vision.

A 29-year-old woman is brought to the emergency department after a caraccident. She complains of head pain and has a contusion over the posterioraspect of the right temporal bone and right occipital bone; a small amount ofblood flows from the right external auditory canal. She has only a vague recollectionof the accident. Past medical history-although difficult to ascertain-seems noncontributory.

A 58-year-old man complains ofintermittent headaches that beganabout 2 months earlier and have recentlyincreased in severity. Theheadaches occur at various times ofthe day and improve slightly whenhe sits. He denies trauma, fever, photophobia,and other neurologicsymptoms. He has 1 alcoholic drinka day and has smoked 1 pack of cigarettesa day for the past 20 years.Medical history is noncontributory.

A 54-year-old Hispanic housewife presents to the emergencydepartment with a 3-week history of moderatelysevere, progressive, generalized, pulsating headache.The headache, which is partially relieved by propoxyphenenapsylate, is associated with weakness, vomiting of recentonset, and intermittent bilateral blurred vision. The symptomsbegan after an incident in which the patient’s sonwas stabbed.

A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had boutsof severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products(ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and mayvomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care centerfor intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. Accordingto the patient, a visit to the urgent care center “completely ruins our day.”

A 45-year-old man has a history of migraine that started shortly after puberty. The headaches became more frequent andsevere 3 years ago, when the patient was promoted from metal worker to shift boss.

A39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.

A 49-year-old man presents with recurring facial pain of 6 months' duration. The pain initially occurred several times per week; it now occurs as often as several times per day. The paroxysmal pain is intense and incapacitating but abates within several minutes. It occurs in the right maxillary region and lower jaw and is sharp and lancinating. Hard chewing and teeth cleaning are the usual precipitating events. Between episodes, the patient is asymptomatic, without numbness or deficit in the affected region.