Headache is a common complaint that afflicts most of the adult population at some point in their lives (Hainer & Matheson, 2013). Headaches are by and large a subjective phenomenon with few objectively measurable factors (McMurtray & Saito, 2014). Most headaches will be the benign, but a small percentage will indicate an underlying neurologic or systemic pathology (Hainer & Matheson, 2013). The purpose of this paper is to investigate the chief complaint, “I have headaches or a headache.” The paper will discuss the objective and subjective data that needs to be collected, headache triggers and drug treatments, and the health promotion strategies that could be helpful to the patient.
1. Subjective Data
The subjective data to ask or listen for in the patient’s narrative in order to identify a primary headache are set out in the International Headache Society classification system (Headache Classification Committee of the International Headache Society, 2013). The International Headache Society (HIS) typically takes headache from a biological point of view and provides a hierarchical diagnostic system based on clinical consensus. Subjective information forms the basis for headache classification in the HIS system. The major categories of the HIS system are primary headaches, divided into tension, migraine or cluster headaches, and secondary headaches, such as those related to an infection or have a vascular etiology. The HIS system is used primarily for research and is detailed, but the basic categories can be identified as follows. Migraine without aura is characterized by at least two of the following symptoms: a duration of 4 to 72 hours, unilateral, pulsating moderate to severe pain, aggravated by routine physical activity and accompanied by nausea, vomiting, photophobia, and phonophobia. A migraine with aura includes focal neurological symptoms, usually visual (aura) that precede the headache. The tension-type headache was once thought to have a psychogenic etiology, but some studies are now finding a neurobiological basis (Headache Classification Committee of the International Headache Society, 2013). Tension-type headaches are characterized by pericranial tenderness that frequently increases with the frequency and intensity of the headache, bilateral with a pressing or tightening quality, duration of a few minutes to days, and mild to moderate pain intensity. Tension-type headaches do not intensify with routine physical activity and are not associated with nausea, however photophobia and phonophobia may also be present (Headache Classification Committee of the International Headache Society, 2013).
2. Objective Data
The HIS classification system is valuable for distinguishing between primary headaches that may be recurrent but do not have a serious underlying condition, and those that are red flags for underlying conditions. Most headaches will be diagnosed by a thorough patient history as physical examinations do not often provide any clues (Hainer & Matheson, 2013). However, objective data would include a patient examination with the following screenings: (1) neurologic examination to rule out underlying neurological conditions, CNS infection, mass lesion, intracerebral infection, (2) neck examination to rule out meningitis, and blood pressure to rule out hypertension. The neurologic examination includes mental status, fundoscopy, eye movement, pupil, visual field, assessment of face for weakness or asymmetry, examination for unilateral limb weakness, coordination of arms, gait assessment and reflex asymmetry. A neck examination consists of range of motion, posture, and palpitation for muscle tenderness (Becker, Findlay, Moga, Scott, Harstall & Taenzer, 2015).
Other objective data obtained for the diagnosis of acute headaches are neuroimaging, blood tests, or erythrocyte sedimentation rate. The warning signals that indicate further objective testing might be required are: age, severity of pain, accompanying symptoms, onset characteristics, and a worsening pattern (Hainer & Matheson, 2013). With respect to onset and pain, the red flags and the reasons for identifying them are: if it is the first headache in the patient’s life, or the worst headache in their experience (CNS infection or intracranial hemorrhage), new headache type if the patient has cancer, HIV, or Lyme’s Disease (respectively, metastsis, tumour or opportunistic infection, meningoencephalitis), new onset with severe pain while pregnant or postpartum (pituitary apoplexy, carotid artery dissection, cortical vein or cranial sinus thrombosis), rapid onset following exercise, coughing, sexual intercourse (subarachnoid hemorrhage, mass lesion), and onset within seconds or minutes (subarachnoid hemorrhage, mass lesion, and bleeding into a mass or an arteriovenous malformation). The dangerous accompanying symptoms are papilledema (pseudotumor, mass lesion, encephalitis, meningitis), change in level of consciousness, personality or cognitive functioning (CNS infection, mass lesion, intracerebral infection) stiff neck or meningismus (meningitis), systemic illness with rash or fever (collagen vascular disease, arteritis, meningitis, encephalitis), tenderness over temporal artery (temporal arteritis, polymyalgia), and focal neurologic signs other than migraine aura (collagen vascular disease, arteriovenous malformation, intracranial mass lesion) (Hainer & Matheson, 2013).
Other warning signs are over the age of 50 (temporal arteritis, mass lesion) and a worsening pattern of headaches (subdural hematoma, medication overuse, mass lesion) (Hainer & Matheson, 2013). Finally, intracranial bleeding or stroke can be brought on by cocaine or methamphetamine use, whereas aspirin or other nonsteroidal anti-inflammatories, and glucocorticoids can cause intracranial bleeding, which could induce a headache (Hainer & Matheson, 2013).
3. Headache triggers and pharmacological treatment
The triggers for primary headache are still poorly understood (McMurtray & Saito, 2014). However, simple observation has indicated several common triggers for recurrent primary headache and they are: stress, over consumption of alcohol, specific smells and lighting in the environment, caffeine, eyestrain resulting from extended use of television or computer, monthly fluctuations of hormones and pregnancy, hypertension, overuse of headache medication and tobacco consumption (Center for Headache Pain and Management, n.d.),
There is a great deal of over-the-counter medications for headache, which results in frequent suboptimal treatment (Becker, et al., 2015). For tension-type headaches, the following drugs are appropriate: ibuprofen (400 mg), SAS (1000 mg), naproxen sodium (500-550 mg), and acetaminophen (Becker, et al., 2015). For migraine headaches the medications are the same with a second line of triptans and antimetics, and third line of naproxen sodium (500-550 mg) in combination with a triptan (Becker, et al., 2015). One in four individuals with recurrent migraine can be helped with prophylactic pharmacological include combination analgesics, triptans, opioids, and ergots (Becker et al., 2015).
4. Health Promotion Strategies
Health promotion strategies regarding primary recurrent headache complaint are easy enough providing the trigger can be identified. Patients frequently identify environmental allergies as triggers for headaches, but this is seldom correct (Center for Headache Pain and Management, n.d.). Headache diaries can be helpful to isolate the factors that trigger headaches. Following migraine and tension-type headaches, medication overuse headaches are the most prevalent, predominantly occur with patients who have migraine headaches or frequent headaches, and resolve after the medication overuse ceases (Yan, Chen, Chen, Li, & Diao, 2015). Behavioral changes that can ward off headache attacks include not skipping meals, getting enough sleep, practicing stress-reducing techniques, and managing lifestyle to avoid stress (Becker, et al., 2015.
Stress is known to play a part in the developmental and psychosocial conditions of headache complaints, but sometimes the triggers are beyond the individual’s ability to control. For example, migraine and tension-type headaches among children and adolescents are associated with interpersonal violence, dysfunctional family dynamics and are co-morbid with psychological problems. Stress contributes to the chronification and exacerbation of headaches, which can persist into adulthood (Stensland, et al., 2014). Health promotion strategies for stress-induced headaches present greater difficulties because the situation calls for a holistic approach including the psychosocial environment of the individual and that could entail psychiatric or social work intervention, for instance, domestic abuse and post-traumatic stress disorder.
In summary, although headaches are a commonplace complaint, it is not a well understood phenomenon. Most of the diagnoses are done on the basis of patient history and subjective data. The etiologic pathways are complex and are likely to be indirect. However, lifestyle and other behavioral changes can lead to a positive outcome.
References
Becker, W. J., Findlay, T. Moga, C., Scott, N. A., Harstall, C., & Taenzer, P. (2015). Guideline for primary care management of headache in adults. Canadian Family Physician, 61(8), 670–679.
Center for Headache Pain and Management, Headache triggers and tips. Mount Sinai Hospital. Retrieved on June 5, 2016 from http://www.mountsinai.org/patient-care/service-areas/neurology/areas-of-care/center-for-headache-and-pain-medicine/headache-triggers
Hainer, B. L. & Matheson, E. M. (2013). Approach to acute headache in adults. American Family Physician, 87(10), 682-687.
Headache Classification Committee of the International Headache Society. (2013). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 33(9), 629–808.
Martin, P. R. (2016). Stress and primary headache: Review of the research and clinical management. Current Pain and Headache Reports, 20(7), 45. doi:
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McMurtray, A & Saito, E. (2014), Does primary headache type influence secondary headache symptoms? Journal of Neuroscience in Rural Practice, 5(2), 111-112. DOI: 10.4103/0976-3147.131644
Stensland, S, Thoresen, S., Wentzel-Larsen, T., Zwart, J-A. & Dyb, G. (2014). Recurrent headache and interpersonal violence in adolescence: the roles of psychological distress, loneliness and family cohesion: the HUNT study. Journal of Headache and Pain, 15:35-44. Available at http://www.thejournalofheadacheandpain.com/content/15/1/35
Yan, Z., Chen, Y., Chen, C., Li, C., & Diao, X. (2015). Analysis of risk factors for medication-overuse headache relapse: a clinic-based study in China. BMC Neurology, 15:168 DOI 10.1186/s12883-015-0422-1
