Reaching a correct diagnosis for patients presenting with chronic head and facial pain can be difficult. Global anxiety, feelings of helplessness, and other mood disorders often co-exist among patients and obscure the physician's ability to acquire the necessary information to form a rational differential diagnosis. A careful interview and documentation of the complete headache history can help establish the correct diagnosis.
The interview should begin with the history of present illness. The anatomic location of headache onset, region of distribution, and temporal or spatial progression of the pain are important descriptors for mapping. The patient should be able to recall the approximate age of symptom onset, and describe the course of progression through the present time. A detailed account of the frequency and timing of attacks, with reference to any known inciting factors should be elicited. The patient should be asked to recall whether the onset of headache is correlated to head or neck position, chewing, stress, consumption of certain foods (e.g., chocolate, nuts, meats or cheeses, alcohol, or caffeine), menstruation, weather changes, or sleep disturbances. A detailed medication history including any newly prescribed medications, changes in drug dosing, or other noted adverse drug effects should be recorded. The duration of each attack as well as quality of the pain (e.g., dull, sharp, throbbing, aching, electrical, pressure sensation) provide important clues to differentiate between myogenic and neuropathic pain. Finally, the patient should be asked about mitigating or alleviating measures, including medications, stress relief, sleep, or preference for a dark, quiet location.
The physician must be aware that headaches may impact other bodily systems other than the head and neck. Rarely is head or facial pain the sole manifestation of the disorder, and associated signs and symptoms should be thoroughly investigated. The patient should be questioned about symptoms, including nausea, fever, visual changes or diplopia, syncope, lacrimation, nasal congestion, photophobia, or phonophobia, either before or during an episode. Migraine headaches may be preceded or accompanied by a reversible aura, consisting of visual, sensory, motor, or brainstem disturbances, such as bizarre scotomata, numbness or tingling of the fingers, feet or lips, and weakness or nausea. In addition, certain headache disorders are heralded by "warning" phenomena or premonitory symptoms, characterized by vague complaints such as hyper- or hypoactivity that may occur hours to days before the onset of pain (3).
Clinical information from the past medical history supplies additional indicators to narrow the diagnostic investigation. A history of trauma, intracranial disease (e.g., meningitis or subarachnoid hemorrhage), or craniofacial surgery may imply a secondary headache disorder. Systemic illness attributable to hypertension, diabetes, venereal disease, or psychiatric illness may warrant additional clinical testing and medical optimization to avoid incorrect treatment of the headache. A comprehensive analysis of all prescription and nonprescription medications taken, with concern for potential adverse effects, is essential. Vasodilators and vasoconstrictors may alter cerebral or extracranial blood flow contributing to headache pathogenesis. Any allergic reactions to medications, foods, or other environmental agents should be clearly documented.
Certain headache disorders appear to relate to the "nature versus nurture" hypothesis with evidence to support both heritable and acquired etiologies. The family history should include both: headache and systemic medical disorders through second-degree relatives. Assessment of familial migraine, TTH, temporomandibular joint disease, intracerebral neoplasia, psychiatric illness, and substance abuse may suggest a congenital headache disorder. Alternatively, the patient's social history may unearth a pattern of maladaptive behaviors that may influence the headache symptomatology. A discussion of smoking, alcohol, and drug use is recommended, in addition to day-to-day stressors such as occupation, finances, marriage, and family.
The physical examination for headache evaluation is guided by the history and pain description; however, a complete physical examination is warranted on the initial visit. Cardiovascular, neuromuscular, and ophthalmological examinations may reveal abnormal findings often missed when examining only the areas of perceived pain. The ears, nose, throat, scalp, and neck should be thoroughly examined as well.
Specific aspects of the physical examination that may reveal subtle findings to help narrow the differential diagnosis include (26):
1. Vital signs.
2. Heart and lung evaluation.
3. Auscultation of the carotid and vertebral arteries, cranium, and orbits for bruits.
4. Range of neck motion for evidence of meningeal irritation.
5. Palpation of the head, neck, and back for trigger points, masses, bruises, or thickened or tender blood vessels.
6. Assessment of the temporomandibular region for tenderness, decreased mobility, asymmetry, clicking, or adjacent muscle hypertrophy.
7. Examination for evidence of papilledema and focal neurological signs indicating possible secondary cause (could include visual field deficits, pupillary asymmetry, sensory deficits of the face, trunk or extremities, asymmetric gait, or motor weakness).
The correct diagnosis of headache is fundamental to implementing an effective treatment regimen and avoiding persistent patient disability. Often the diagnosis will be clear following a thorough patient history, although occasionally additional testing is required. This is especially true when focal neurological signs are found, and a secondary headache disorder is suspected. On occasion, testing is warranted for patients who are disabled by their fear of serious pathology, or when the physician has concerns despite the lack of organic pathology indicators. Nevertheless, various guidelines have been put forth to assist the physician in deciding whether additional diagnostic testing is indicated.
Neuroimaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in the evaluation of headache to assess for structural pathology. Certain headache indicators have been shown to increase the likelihood of an abnormal finding on cranial imaging, including rapidly increasing headache frequency, history of coordination difficulty, focal neurological signs or symptoms, and headache awakening one from sleep (27). According to the American Academy of Neurology, for those patients with a chronic headache disorder, "with no recent change in pattern, no history of seizures, and no other focal neurological signs or symptoms, the routine use of neuroimaging is not warranted" (28). When the headache presentation is atypical or accompanied by seizure, CT or MRI may be indicated.
The electroencephalogram (EEG) has been used historically as an adjunct to neuroimaging in the diagnostic evaluation of headache. It was suggested that EEG may identify structural abnormalities in the brain among certain individuals with headache, warranting further diagnostic evaluation. An evidence-based review of the literature by the American Academy of Neurology failed to find sufficient evidence supporting its utility in the routine evaluation of headache (29). If the purpose of the EEG is to exclude an underlying structural lesion, such as a neoplasm, CT or MRI is far superior.
Lumbar puncture is indicated in headache evaluation under certain conditions, such as a first or worst migraine or a crash migraine to exclude subarachnoid hemorrhage or meningitis. Lumbar puncture can also be diagnostic of meningeal carcinomatosis or lymphomatosis, and high or low cerebrospinal fluid pressure (30). The cerebrospinal fluid is usually normal in patients with migraine, although in rare cases, the protein concentration may be increased because of an altered blood-brain barrier when the migraine is frequent and severe or associated with cerebral infarction (31). Radiographic imaging to rule out any cause for asymmetric cerebral pressures should precede lumbar puncture.
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