Headache

History

Key questions in patients with headache is:

What is my diagnosis and do I have any evidence not to order a MRI and perform a LP?

Headache with any of the following characteristics should prompt further investigation:

·        new-onset headache (days (e.g. SAH) to months (e.g. cryptococcal meningitis) even when subtle in nature

·        when atypical and not fulfilling the diagnostic criteria

·        triggered or increasing in intensity by bending over, coughing, sneezing, bowel movements, weight lifting

·        exhibiting a particular diurnal (e.g. worse in the afternoon) or nocturnal pattern

·        exacerbation of existing headache with changes in characteristics

·        atypical or new-onset "migraine-like" headache related to hormonal changes (menses, pregnancy)

·        when association with other neurological symptoms or signs, including low back pain

·        severe stabbing/throbbing nuchal and/or neck, or facial pain, even when recurrent

 Never accept from the patient that the CT/MRI was "normal" until you have actually seen it!

Screening tests

Serum glucose, electrolytes, calcium/phosphorus, magnesium, liver, renal and thyroid function tests

CBC, ESR

CSF pyruvate and lactate (mitochondrial disorders)

EEG (see history)

Brain CT/MRI scan (see history)

Specific tests

Blood/serum

NH₃