Lifesaving Questions for Patients With Acute Headache

December 31, 2006

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.

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. In the history taking, she indicated that her migraineswere always unilateral. She was not examined. The patient's headacheresolved with intravenous prochlorperazine, and she was discharged. Eighteenhours later, she was found unresponsive, and she died shortly afterward of asubarachnoid hemorrhage.The authors make 2 fundamental points regarding this case:A change in the clinical presentation of an existing condition requires anevaluation as if the patient had a new complaint.A patient with a neurologic complaint requires a neurologic examination.While a neurologic examination certainly should have been performed, itmight or might not have revealed abnormal findings in this case. However, amore carefully elicited history might have saved the patient's life. Key questionsto ask patients who present with acute headache include:Is this the worst headache of your life?How long was it from the onset of this headache to its maximum intensity?In patients with headaches that have begun within the previous 72 hours,an affirmative response to the first question almost always indicates the needfor an immediate CT scan and, if the CT results are normal, a lumbar puncture.An explosive "thunderclap" headache that reaches maximum intensity inseconds also mandates a CT scan and a follow-up lumbar puncture if the CTresults are normal."The worst headache of one's life" and an explosive headache with rapidonset represent "headache alarms" that indicate a need for immediate furtherevaluation. Other alarms include head injury, fever, immunosuppression, anda change in level of consciousness.--Eric Schuman, MPAS, PA-C
   Salem, Ore

Thank you for your comments. You have made some excellent pointsthat are well worth emphasizing.-- Andy Jagoda, MD
   Professor of Emergency Medicine
   Mount Sinai School of Medicinev   New York
-- Silvana Riggio, MD
   Associate Professor of Psychiatry
   Mount Sinai School of Medicine
   Director, Schizophrenia Treatment and Research Program
   Bronx Veterans Administration Mental Health Patient Care Center
   New York

References:

FOR MORE INFORMATION:

  • Dodick DW. Thunderclap headache. J Neurol Neurosurg Psychiatry. 2002;72:6-11.
  • Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med.2000;342:29-36.