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🌱 來自: Huppert’s Notes
Approach to Headaches🚧 施工中
Approach to Headaches
• History:
- Is this an old or new headache? If old, how do the current headaches differ?
- What’s the headache phenotype?
• PQRST:
- Provocation – associated with stress, foods, posture, menstruation, lack of sleep?
- Palliation – which medications have been tried, how often, treatment response?
- Quality
- Quantity
- Region – unilateral or bilateral?
- Radiation – from neck or jaw? (may suggest cervicogenic headache or TMJ-associated headache)
- Symptoms – nausea/vomiting, photo/phonophobia, lacrimation/rhinorrhea, aura?
- Timing – frequency (including # of h/a per month), duration, onset (gradual or thunderclap), worse in morning (suggests increased ICP)?
- Are there features suggestive of a primary headache disorder?
• Associated features: Photo/phono/osmophobia, N/V, restlessness/agitation (TACs), allodynia?
• Aura: Visual scotoma, scintillations, wavy lines in vision, photopsia, paresthesias?
• Autonomic features (unilateral): Eye tearing, periorbital discoloration, ptosis or eyelid edema, conjunctival injection, nasal congestion/discharge, forehead/face sweating/flushing?
• Triggers: Menses, alcohol, bright lights, loud sounds, weather changes, dehydration, skipped meals, stress, poor sleep?
• Are there any headache red flags? SNOOP
- Systemic symptoms
- Neurologic signs/symptoms
- Older age of onset (>50 yr)
- Onset (sudden “thunderclap” headache)
- Papilledema, Positional (worse when supine → intracranial hypertension; worse when upright → intracranial hypotension), Precipitated by Valsalva, Pregnant or Post-partum, Pattern change)
• Physical exam:
- Blood pressure and heart rate, palpate neck/shoulder for trigger points, evaluate spine and paraspinal musclces, palpate temporal arteries, ascultate for bruits, neurologic exam (including fundoscopic exam)
• Imaging:
- Indications for imaging include focal neurologic deficients, onset with exertion, new onset >50 yr, recent change in headache pattern, positional headache
- MRI preferred but start with NCHCT in the acute setting
• Labs:
- Consider checking ESR/CRP in patients >50 yr given risk of giant cell arteritis