A
ccording to data from the World Health Organization (WHO), headaches are among the 10 disorders resulting in the most severe functional impairments worldwide (1). Interestingly, most results from studies of the epidemiology of idio-pathic headache show that the prevalence is very similar throughout the world when the same instruments are used to measure headache. These results favor a biological cause and make strong sociocultural or ethnic influences in headache less likely. Th e prevalence of headache disorders worldwide is 60%.The International Headache So-ciety (IHS) developed an exact classification system for headache (2). The populati-on-related lifetime prevalence of the different types of headache has been investigated in an exemplary fashion in a Danish study; the exact figures are shown in b ox 1(3).Headache is also greatly important from a socioeconomic perspective (4). Th e direct costs of headache disorders, i.e., the costs of outpatient and inpatient treat-ments, prescribed drugs, and sickness pay, is an estimated 450 million per year for migraine patients alone, in spite of the fact that only about half of the appro-ximately 8 million migraine patients in Germany visit their doctor. Most headache patients self-medicate with over-the-counter painkillers; again, migraine patients
incur costs of some Euro 500 million.
The indirect costs of headache disorders, such as inability to work and reduced productivity, exceed the direct costs by a multiple. Days of sickness absence due to migraine equals the annual working time of 185 000 full-time employees. Th e costs are estimated at about 3.5 billion annually; this does not include the loss in productivity in people who are not in formal employment, such as housewives or carers of children or family members. Invalidity and incorrect treatment incur the
SUMMARY
Introduction: Headache has a high epidemiologic and socioeconomic impact. An early, accurate differential diagnosis is important in order to avoid chronification and loss of productivity. Methods: Overview of the different headache disorders based on a selective liteature review. Results: The classification follows the International Headache Society´s categorization. More than 90% of all headaches in medical care are idiopathic in origin; it is rare that headache is the first symptom of dangerous disease. Migraine, tension-type headache, and the different subtypes of trigeminoautonomic headache, with their characteristic patterns, must be considered in the differential diagnosis of primary headache. Subarachnoid haemorrhage and other bleeding related causes are the most important differential diagnoses. Dtsch Arztebl 2006; 103(45): A 3040–8. Key words: migraine, tension-type headache, trigeminoautonomic headache, symptomatic headache, subarachnoic haemorrhage
Klinik und Poliklinik für Neurologie, Universitätsklinikum Münster (Prof. Dr. med. Dr. phil. Evers, Dr. med. Frese, Dr. med. Marziniak)
cme:
Differential
Diagnosis of Headache
Stefan Evers, Achim Frese, Martin Marziniak
Prevalence
Headache is one of the most common health
problems. The lifetime prevalence of episodic
tension-type headache is 70%, that of
migraine 15%.
This text is a translation from the original German which should be used for referencing. The German version is authoritative.so-called tertiary costs in this context. Modeling the costs incurred by this is ex-tremely difficult. Other types of headache, including tension-type headache, show a markedly higher prevalence. The lower frequency and intensity of headache in this group of patients, however, lowers the costs, so that the economic burden (including working hours lost) due to all other types of headache combined is of a similar magnitude to the costs due to migraine patients.
In this article, we make recommendations for the pragmatic, clinically oriented diffe-rential diagnosis of headache.These are based on the guidelines of the German society for migraine and headache (Deutsche Migräne- und Kopfschmerzgesellschaft,
Costs incurred by headache disorders
The direct costs incurred by headache
in Germany are some 2 billion, the
indirect costs some 7 billion.
BOX 1
Population-based prevalence of the different
types of headache disorders*
1>Migraine Without aura 9% With aura 6% >Tension-type headache Episodic 66% Chronic 3%
>Cluster headache and other trigeminoautonomic headache 0.1% >Other idiopathic headache
– Idiopathic stabbing headache 2% – Primary cough headache 1%
– Primary exercise-induced headache 1% – Headache during sexual activity 1% >Headache secondary to skull trauma 4% >Headache caused by vascular disorders 1%
>Headache caused by non-vascular intracranial disorders (e.g. tumors) 0.5%
>Headache caused by drug overuse 3% >Headache in infection or fever 63% >Headache in metabolic disorders 22% >Headache in disorders of the
– Throat 1% – Eyes 3% – Ears 0.5%
– Nose or sinuses 15%
>Neuralgias of the head or face 0.5%
*1 in the 1988 classification in Denmark as per (3). The lifetime prevalence of headache generally was 93% for men and 99% for women.
DMKG), on an analysis of review articles on the differential diagnosis of headache, and on the authors’ clinical and scientific experience.
Diagnostic principles
The IHS classification subcategorizes headache into two large main categories: idio-pathic headache and symptomatic headache (i.g. headache symptomatic of underly-ing disease). Idiopathic headache is diagnosed exclusively accordunderly-ing to criteria that take into account the symptoms. The diagnosis by etiology, which was used even into the 1980s-for example, vascular headache or muscle contraction headache-has been
abandoned. The IHS
classification has been available in its second (revised) version, and a German-lan-guage version is available (5).
According to the IHS classification, a careful history is crucial to making the cor-rect
diagnosis. Neurological and general physical examination and additional apparative diagnostics are used in individual cases for the purpose of exclusion-for example, t o identify symptomatic headache. The treating physician is advised to conduct a physi-cal examination for the initial diagnosis of idiopathic headache. The physiphysi-cal exam needs to include the components shown in b ox 2.
Apparative diagnostics for idiopathic headache are not currently available. More than 90% of all headache disorders that prompt patients to visit their doctors are idiopathic. In spite of this, most patients are scared of symptomatic headache becau-se they often fear that a brain tumor might be the caubecau-se. In some cabecau-ses it therefore makes sense for the doctor during the initial consultation to initiate additional appa-rative diagnostics, such as cerebral imaging, even if no formal indication exists. If the
Diagnosis
The IHS classification categorizes
headache disorders into idiopathic and
symptomatic types.
BOX 2
General and neurological examination for the
initial diagnosis of headache
>neurological exam (with special consideration of the status of the cerebral nerves, reflex status, sensation, coordination and locomotor system, basic neuropsychological test)
>Examination of the cervical spine (mobility of the upper segments of the cervical spine, pain on exertion of pressure on the pericranial muscles) and inspection of the entire spine
>Examination of the jaw function and orthodontic status, including mucous membranes
>Blood pressure measurement
>Assessment of vascular status (temporal artery, auscultation of the A. carotis) >Auscultation of heart and lung
>Palpation of the abdomen >Inspection of the skin
neurological findings are inconspicuous, then a lesion may be expected on the image in only 0.4% of migraine patients, which in most cases is not even the reason for the
headache (6). In case of positive findings
from the neurological exam, the risk of a lesion increases up to 15%. The diagnostic recommendations also apply to special situations, such as headache in pregnancy or childhood (7). The exact wording of the headache classification and the therapeutic recommendations of the German society for migraine and headache are available on the internet (www.dmkg.de).
Categorization of headache
Headache and facial pains are classified into 14 main categories, which are subcate-gorized into more than 200 different types of headache.B ox 3summarizes the main groups. What follows is a short explanation of the most important types of headache from a differential diagnostic perspective.
Migraine
Migraine is by far the most common type of idiopathic headache that causes patients to consult a doctor. As migraine and its various manifestations have been the subject of a CME article previously, we will not discuss this any further here (see May A: Dia-gnostik und moderne Therapie der Migräne; Dtsch Arztebl 2006; 103[17]:A1157-66).
Migraine
Migraine is by far the most common
idiopathic type of headache that brings
patients into surgeries.
BOX 3
Categorization according to the
International Headache Society's classification
of headache disorders
>Idiopathic headache – Migraine
– Tension-type headache
– Cluster headache and other trigeminoautonomic headache disorders – Other primary headache
>Symptomatic headache disorders Headache caused by:
– Trauma to the head or cervical spine – Vascular disorders in the head or neck areas – Non-vascular intracranial disorders – Substance use or withdrawal – Infection
– Homeostasis disorders (metabolic disorders)
– Disorders of the skull, throat, eyes, ears, nose, sinuses, teeth, mouth, or other structures of the face or skull
– Psychiatric disorders (somatization disorders, psychotic disorders) – Cranial neuralgias and central causes of facial pain
– Non-classifiable headache
How common is headache?
90% of all patients presenting in clinical
practice have idiopathic headache, which is
positively diagnosed only by taking a thorough
history.
Standardized therapy recommendations and recommendations about apparative diagnostics have been
published by the responsible scientific societies (8, 9).B ox 4lists the criteria that
should be used to determine whether imaging should be done in suspected migraine.A CME article on
this
topic has been published (see Krings T: Bildgebende Diagnostik bei der Abklärung des Kopfschmerzes; Dtsch Arztebl 2004; 102 [45]: A3026-35).
Tension-type headache
Tension-type headache has the highest lifetime prevalence, but it usually affects pa-tients less severely and therefore prompts them to visit their doctor less often than migraine does.B ox 5shows the diagnostic criteria of this type of headache. The cli-nical course can be used to differentiate between the subcategories:
> Less than 12 days per year: sporadically occurring, episodic, tension-type head-ache
> 12 to 180 days per year: frequently occurring, episodic, tension-type headache
> More than 15 days per month: chronic tension-type headache.
Especially chronic tension-type headache is easily mistaken for symptomatic headache in differential diagnosis. This may be the case when, e.g., normal-pressure hydrocephalus, chronic subdural hematoma, or post-traumatic headache is the cau-se. For this reason, in chronic tension-type headache, cerebral imaging should always be undertaken, in individual cases followed by apparative diagnostics.
Trigeminoautonomic headache
Trigeminoautonomic headache is defined as a group of headache disorders that oc-cur
Tension-type headache
Tension-type headache disorders are
subcate-gorized into an episodic and a chronic form.
The chronic type as a lifetime prevalence of up
to 3% and is often refractory to treatment.
Trigeminoautonomic headache
Trigeminoautonomic headache disorders
include strictly unilateral headache with
autonomous accompanying symptoms.
Cluster headache is the best-known form.
BOX 4Migraine-magnetic resonance imaging should be
undertaken to rule out symptomatic headache in:
>First manifestation of migraine with untypical headache or untypicalaccompanying symptoms
>Migraine with untypical (especially persistent) aura, any form of migraine with hemiplegic aura
>First manifestation of migraine in a patient older than 40
>Conspicuous findings in the general and neurological physical exam >Atypical clinical course (i.e., significant changes to frequency, duration,
accompanying symptoms)
>Increasing intensity of pain or changing character of headache; when previously effective medication ceases to work
>Patient reports new, additional neurological symptoms/deficiencies >Patient fears serious underlying disorder, such as tumor
paroxysmally, are accompanied by unilateral trigeminal pain and obligatory autono-mous accompanying symptoms (10, 11).This means that strictly unilateral, periorbital, or temporal pain attacks occur, and that at least one of the following symptoms coin-cides with the pain: lacrimation, rhinorrhea, red eye, or Horner syndrome.
The best-known type of headache in this group is the cluster headache. This inclu-des
paroxysmal hemicrania and SUNCT syndrome ("short lasting unilateral neuralgi-form headache attacks with conjunctival injection and tearing").These different neuralgi-forms are clinically distinguishable primarily by the time pattern of the attacks in terms of
duration and frequency. They can all occur episodically as well as in a chronic pattern. If the
epi-sodic form is present, the patient will have almost daily attacks over a space of weeks
Idiopathic headache
Rare forms of idiopathic headache occur
during exercise, cough, sexual activity, as
"thunderclap headache," or the headache pain
is stabbing or occurs only at nighttime.
BOX 5
Operationalized diagnostic criteria of
tension-type headache *
1A. At least 10 episodes that meet criteria B to D (on a maximum of 15 days per month)
B. Duration of headache is between 30 minutes and seven days
C. The headache displays a mmiinniimmuumm ooff ttwwoo of the following characteristics: 1. Bilaterial localization
2. Pain is heavy or compressing, not pulsating 3. Intensity of pain is light to medium
4. Pain does not increase through physical routine activities, such as walking or climbing stairs
D. Both of the following criteria are met:
1. No nausea or vomiting (loss of appetite is possible) (in chronic forms, nausea may occur)
2. Either photophobia or phonophobia, but not both, may be present E. Headache is not caused by another disorder
*1According to the headache classification of the IHS TABLE
Differential diagnosis of the different types of trigeminoautonomic headache
Duration Daily Autonomous Effectiveness frequency symptoms of indometacin
Hemicrania continua Permanent Permanent (+) + Cluster headache 15–180 min 0.5–8 + – Paroxysmal hemicrania 2–30 min > 5 + + SUNCT syndrome 5–240 sec 3–200 + – Trigeminal neuralgia < 2 sec Undetermined – –
or a few months. Intermittently, however, the symptoms may subside totally for a ti-me period of up to three months. The tableshows the different time patterns.
A particular feature of paroxysmal hemicrania is that it always and completely re-sponds to indometacin (daily dosage: up to 200 mg). This is an obligatory diagnostic criterion. The tablealso lists hemicrania continua, which also responds to indometa-cin but does not occur paroxysmally but is continuous. This type of headache is clas-sified into the group of other idiopathic headache. In addition, trigeminal neuralgia
has to be differentiated from trigeminoautonomic headache. In trigeminal neuralgia, the attacks are short
(most-ly less than one second) and do not have any autonomous, accompanying symptoms (12).
Confirmatory magnetic resonance imaging of the skull should be undertaken in all trigeminoautonomic headache disorders, as cases have been described where tumors or vascular malformations give rise to headache in the midline or occipital area. Other idiopathic headache
Within the headache classification, a group of idiopathic headache disorders is men-tioned that cannot be categorized into the three groups described previously (13). These headache disorders are harmless, and it may be assumed that they have no fur-ther significance. They are more common in the population than one might think, gi-ven how little known they seem to be. These headaches can be described as follows:
> Idiopathic stabbing headache: brief, stabbing headache in changing locations in the skull without any further accompanying symptoms
> Primary cough headache: headache lasting minutes in case of a cough or other Valsalva maneuvers (symptomatic in Arnold-Chiari syndrome)
> Primary exercise-induced headache: occurs in case of physical exertion or du-ring sports activities and lasts for hours
> Headache during sexual activity: bilateral occipital headache that occurs espe-cially shortly before or during orgasm and lasts minutes to hours (caution: subarachno-id hemorrhage needs to be ruled out)
> Primary sleep-related headache, so-called hypnic headache: headache attacks that last a few hours and affect primarily elderly people and occur exclusive at night-time (often at the same night-time)
> Primary thunderclap headache: headache that reaches maximum intensity wit-hin a minute and can last between hours and days. In spite of extensive diagnostics, no cause can be found (caution: subarachnoid hemorrhage needs to be ruled out).
Diagnostics in case of suspected symptomatic headache
If the headache does not meet the typical criteria for idiopathic headache, or if the history or neurological investigations give reason to suspect symptomatic headache, further
apparative diagnostics and possibly further specialist investigations will need to be in-itiated. We will discuss headache disorders that may result in lasting impairment or even death if diagnosis is delayed, and that may not show up in cranial imaging (such
as computed tomography or magnetic resonance imaging of the head). Within the constraints of
the
objectives of this article we can present only the diagnostic fundamentals.B ox 6 gi-ves an overview of the different apparative diagnostics that can be used.
When is imaging indicated?
To rule out symptomatic forms among the
rare idiopathic headache disorders, cerebral
imaging should be undertaken.
Subarachnoid hemorrhage
The lead symptom is sudden-onset headache of unfamiliar intensity, which is often followed by neck pain with a slight time delay, and in 50% of cases is accompanied by nausea,
vomiting, and impaired consciousness. Focal deficits or epileptic fits point at a he-morrhage of the brain parenchyma, but these symptoms are not obligatory. On clini-cal examination, photophobia and stiffness of the neck are often found. If a
suba-rachnoid hemorrhage is clinically suspected, cranial computed tomography (CT) scanning is urgently
requi-red.This test has a sensitivity of over 95% if performed within the first 48 hours after onset of headache. Magnetic resonance imaging (MRI) with "fluid attenuated inver-sion recovery" (FLAIR) sequences and gradient echo sequence is equal to compu-ted tomography in the acute phase; the sensitivity of compucompu-ted tomography, howe-ver, drops the greater the time delay after headache onset and is <50% after a week, whereas magnetic resonance imaging shows blood degradation products even after
BOX 6
Value of different apparative diagnostics in the
differential diagnosis of headache
>Magnetic resonance imaging of the skull
– parenchymal lesions (including inflammatory plaques and encephalitis) and hemorrhages (subarachnoid hemorrhage, subdural hematoma);
representation of the brain stem and the pituitary region as well as the base of the skull (e.g., Arnold-Chiari malformation); dissections (targeted sequences in axial cross-section of the neck); on magnetic resonance angiography sinus thrombosis and larger aneurysms are found
>Computed tomography scanning
– Bones; early detection of blood in CSF (subarachnoid hemorrhage, subdural hematoma); on magnetic resonance angiography sinus thrombosis and larger aneurysms are found
>Digital substraction angiography
– Smaller aneurysms; smaller thromboses of the cerebral veins, cerebral vasculitis, arteriovenous fistulae; extracranial and intracranial fistulae >Ultrasonography
– Representation of dissections (especially of how they are controlled) >Electroencephalogram
– Epileptic seizures; course of the focal EEG changes in suspected migraine aura
>Radiography of the cervical spine
– Bone destruction; post-traumatic changes including spondylolisthesis; structural disorders; not suitable for proving headache caused by cervical spine
>Radiography of the sinuses – Sinusitis
Radiography of the skull and
cervical spine
A native x-ray of the skull and the
cervical spine is not appropriate in the
diagnosis of headache.
Subarachnoid hemorrhage
In case of suspected subarachnoid hemorrhage, computed
tomography scanning should be undertaken immediately. If this
does not show up anything then a lumbar puncture is required.
If the lumbar puncture does not show up anything, angiography
should be performed.
a longer time period (14).
If CT and MRI are negative and subarachnoid hemorrhage is suspected, the treating physician should initiate cerebrospinal fluid (CSF) analysis.The CSF analysis should be conducted with a time delay of 6 to 12 hours after headache onset as, at an ear-lier time, differentiation between subarachnoid hemorrhage and artificially bloody CSF may not be possible. Several hours after the subarachnoid hemorrhage, erythrocyte lysis occurs and bilirubin and oxyhemoglobin form, which gives the CSF a yellow coloration after centrifuging.
This so-called xantochromia can be found up to two weeks after a subarachno-id
hemorrhage. Bilirubin also shows up on spectrophotometry and is proof that a suba-rachnoid hemorrhage has occurred because bilirubin can form only in vivo. Ferritin and siderophages can be found in CSF until up to four weeks after the hemorrhage, but a hemorrhage cannot be proved at a later date. If a patient presents only sever-al weeks after the event, CT or MR angiography should be considered to document the presence of an aneurysm because this may show that a subarachnoid hemorrha-ge has occurred. This method is controversial, however, since small, asymptomatic aneurysms (<5 mm) may be expected in one in 50 adults.
Subdural hematoma is another form of brain hemorrhage that may become sympto-matic primarily with headache similar to chronic tension-type headache (figure). Espe-cially in elderly patients this should be considered after minor trauma, during treatment with phenprocoumon, or in case of low CSF pressure. The diagnosis can be confirmed with CT and MRI.
Meningitis
Bacterial meningitis is characterized by three clinical symptoms: headache, stiffness of the neck, and fever. Additionally, vegetative symptoms (photophobia, nausea, vo-miting) and impaired vigilance as well as epileptic seizures may occur. Exanthema, especially on the trunk and the legs, points at meningococcal meningitis but may also occur in pneumococcal or haemophilus meningitis. The definitive diagnostic measu-re is CSF analysis, which usually shows a granulocytic pleocytosis of >1 000 cells/µL.
Figure
Subdural hematomas on the magnetic resonance scan of a patient aged 76 who presented with chronic, post-traumatic headache that was refractory to treatment
Giant cell arteritis
Giant cell arteritis (formerly temporal arteritis)
is diagnosed by history, typical laboratory variables,
and a biopsy if required. Even in case the diagnosis
is not clear, steroid treatment has to be initiated
immediately.
Lower granulocytosis measurements can be observed early on in the course of the disease, in patients who have not received antibiotics, in cases of fulminant illness with a high density of bacteria, and in immunocompromised patients.The CSF analysis en-ables confirmation of the causative strain by microscopy (gram staining), antigen de-tection and culture, and a later adaptation of the empirical initial treatment after re-sistogram.
In patients with suspected bacterial meningitis without impaired vigilance or focal neurological deficit, the CSF analysis should immediately follow the clinical exami-nation, and antibiotic treatment should be initiated after blood cultures have been taken. In patients with impaired consciousness or focal neurological deficits, cranial CT scanning should be performed before CSF analysis, so that increased intracrani-al pressure with the danger of incarceration can be excluded. In this case, the anti-biotic treatment has to be started after blood cultures have been taken, and CSF should be taken as soon as CT scanning has ruled out any contraindication. Usually, CSF analysis enables differentiation from viral meningitis, which normally takes a blander clinical course.
Giant cell arteritis (temporal arteritis)
Giant cell arteritis is a disorder that typically affects elderly people. It manifests acutely or
subacutely, with general symptoms of illness (unspecific malaise, subfebrile temperatu-res, loss of appetite, maybe weight loss) and unilateral or bilateral stabbing-drilling
headache. Visual
disturbances (amaurosis fugax, visual strain) are further cardinal symptoms and if dia-gnosis and treatment are delayed, these indicate the threat of impending blindness. Ty-pical further symptoms include jaw claudication and dysesthesias or necroses of the skin on the head, but these are not always present. Often, the temporal artery is
pain-fully hardened and shows a diminished pulse. Characteristic laboratory findings include a high increase in C-reactive
protein and BSG (erythrocyte sedimentation rate,ESR,drops drastically).Increase in C-reactive protein has a higher sensitivity.The diagnostic gold standard is a histologic
fin-ding of necrotizing giant cell arteritis in a biopsy sample from the temporal artery.
A biopsy should be initiated without further ado, especially in case of untypical clinical presentation or if the ESR is normal. As the sensitivity of the biopsy decrea-ses continually during treatment with steroids (from 80–90% to about 60% within a week), it should also be undertaken early on. Under no circumstances, however, must there be a delay in starting steroid treatment because otherwise an irreversible
loss of vision may occur. Giant cell
arteritis occurs in >50% of cases alongside a polymyalgia rheumatica, which is charac-terized by myalgia of the shoulder and pelvic muscles and by arthralgias.
Sinus thrombosis
A thrombosis of the cerebral veins occurs typically during pregnancy, in hereditary coagulopathies, or in bacterial meningitis and often results primarily in vice-like headache that is worse in a supine position than in an upright position. A pseudotu-mor cerebri may follow. Defects of the cerebral nerves, unilateral symptoms, and ty-pically epileptic seizures may occur. Magnetic resonance imaging should be
under-Sinus thrombosis
A sinus thrombosis may be the cause of
chronic headache (especially during
pregnancy). The only way to diagnose
this is by imaging.
taken speedily because in most cases a morphological image of the brain is not
suffi-cient, but MRI angiography with
a venous phase will have to be performed. In case of doubt, conventional digital sub-traction
angiography (DSA) may be indicated.
Dissections of the cerebral arteries
Traumatic dissections, which are often caused by chirotherapy, or spontaneous diss-ection of the cerebral arteries can lead to sudden-onset unilateral headache or neck ache.These are a common cause of cerebral ischemia in young people, although they do not necessarily result in ischemia. Several days may pass between the occurrence of a vascular dissection and cerebral ischemia, during which MRI may not show any findings. In this phase, unilateral Horner syndrome may point at a dissected internal carotid artery with hematoma-related damage to the sympathic nerves; similarly, h e-matoma-related deficits of the caudal nerves may occur, such as difficulties swallo-wing, lingual paresis, and dysarthria. Ultrasonography of the neck vasculature may show hemodynamic or morphologic signs that may raise suspicion of a dissection. However, ultrasonography as the only diagnostic procedure often cannot provide a clear differential diagnosis to other vascular pathologies, such as atherosclerosis. Magnetic resonance angiography with MR cross-sectional images almost always de-tects the dissection and has therefore taken over from DSA as the gold standard.
Pseudotumor cerebri
This disorder is defined as an increased CSF pressure without a finding of a space oc-cupying lesion and with no findings on CSF analysis.The lead symptom is a headache that is often pulsating. Eye strain, visual field losses, tinnitus, loss of vision, and
double vision may accompany this disorder, in descending order of frequency. The disorder affects
mainly overweight women of childbearing age, but can also affect men in rare cases.A characteristic finding is a choked disk; in case of neuropathy of the optical nerve
pe-rimetry shows an enlarged blind spot and visual field defects concentrating on the lower nasal region. A
cerebral, space occupying lesion and sinus thrombosis have to be ruled out. The defi-nitive diagnostic measure is CSF measurement in a supine position, which is >25 cm H2O and is followed by the immediate release of 20 to 30 ml CSF as a short-term the-rapeutic measure.
Brain tumors
Headache due to brain tumor is extremely rare and is the single or initial symptom in less than 0.1% of all headache patients (15). Almost all headache patients, however, are afraid of a brain tumor. A tumor as the cause of headache needs to be considered only if the neurological examination unequivocally shows focal neurological (i.e. loca-lized) deficits, if the headache is newly accompanied by an epileptic seizure, or if vo-miting occurs in the morning.
This article has been certified by the North Rhine Academy for Postgraduate and Continuing Medical Education.
The Deutsches Ärzteblatt provides certified continuing medical education (CME) in accordance with the requirements of the Chambers of Physicians of the German federal states (Länder). CME points of the Chambers of Physicians can be acquired only through the Internet by the use of the German version of the CME questionnaire within 6 weeks of publication of the article. See the following website: www.aerzteblatt.de/cme.
Participants in the CME program can manage their CME points with their 15-digit "uniform CME number" (einheitliche Fortbildungsnummer, EFN). The EFN must be entered in the appropriate field in the www.aerzteblatt.de website under "meine Daten" ("my data"), or upon registration. The EFN appears on each participant's CME certificate.
Question 1
Which headache disorders are symptomatic headache disorders?
a) Migraine
b) Tension-type headache c) Primary, sleep related headache d) Cluster headache
e) Pseutotumor cerebri
Question 2
Which disorder is one of the trigeminoautonomic headache disorders?
a) Giant cell arteritis (temporal arteritis) b) Chronic cluster headache
c) Sleep-related headache d) Primary cough-related headache e) Trigeminal neuralgia
Question 3
Which symptom rules out chronic, tension-type headache?
a) Unilateral headache b) Mild nausea c) Loss of appetite d) Vice-like headache e) Vomiting Question 4
How many days or months does a headache have to persist to qualify as a chronic, tension-type headache? a) 5 days/month b) 10 days/month c) 15 days/month d) 20 days/month e) 30 days/month Question 5
When should computed tomography scanning be undertaken in suspected subarachnoid hemorrhage?
a) Never; magnetic resonance imaging should always be done first b) As quickly as possible
c) Only after a lumbar puncture
d) A minimum of four hours after the event e) As soon as neurological deficits occur
Question 6
Which laboratory variable has the highest sensitivity in a case of giant cell arteritis?
a) Erythrocyte sedimentation rate b) Leukocyte count
c) Fibrinogen d) Hemoglobin
Please answer the following questions to participate in our certified
Continuing Medical Education program. Only one answer is possible
per question. Please select the answer that is most appropriate.
Question 7
What is the purpose of magnetic resonance imaging in suspected trigeminoautonomic headache?
a) To prove contact between a vessel and a nerve
b) To rule out symptomatic headache (e.g., tumor of the posterior cranial fossa) c) To rule out a cerebellar infarction as a cause of the pain
d) To rule out epilepsy before an antiepileptic is administered for pain relief e) To identify migraine as the cause of unilateral headache
Question 8
Which fundamental principle of criteria is used to diagnose idiopathic headache in the headache classification of the International Headache Society?
a) On the basis of apparative diagnostics
b) On the basis of etiologic criteria (pathophysiologically) c) On the basis of symptoms
d) On the basis of the family history
e) On the basis of criteria in the physical exam
Question 9
Which headache is an idiopathic headache?
a) Headache in giant cell arteritis b) Headache in arterial dissection c) Headache in bacterial meningitis d) Headache in subarachnoid hemorrhage e) Headache during sexual activity
Question 10
Which statement is correct with respect to diagnosing headache?
a) Most headache presented in medical practice is idiopathic and not symptomatic b) To diagnose migraine, cerebral imaging will have to be conducted
c) Unilateral headache rules out a tension-type headache
d) Neurophysiological methods do not have a role in diagnosing symptomatic headache
Important Information
The Deutsches Ärzteblatt provides certified continuing medical education (CME) in accordance with the requirements of the Chambers of Physicians of the German federal states (Länder). CME points of the Chambers of Physicians can be acquired only through the Internet by the use of the German version of the CME questionnaire within 6 weeks of publication of the article. See the following website:www.aerzteblatt.de/cme.
The correct answers to this CME questionnaire will be published in issue 1–2/2007 under this heading.
The planned CME topic in Issue 49/2006 is "Psychopathology and Treatment of Borderline Personality Disorder".
Correct answers to the CME questionnaire in issue 37/2006: Börgermann C, Rübben H: Early Detection of Prostate Cancer: 1/c, 2/b, 3/b, 4/d, 5/e, 6/d, 7/d, 8/b, 9/e, 10/a
Case report:
Headache as a result of dissections
ADDITIONAL MATERIAL
This text is a translation from the original German which should be used for referencing. The German version is authoritative.A 40-year-old patient presented with headache on the left-hand side, which radiated from the neck to the temple.
The headache had first developed after a chiropractic treatment of the cervical spine, which had been conducted successfully for neck and shoulder pain. On clinical-neurological examination, the patient was found to have left sided Horner syndrome, but nothing of note was fo-und otherwise. In Doppler ultrasonography – fo-undertaken immediate-ly – accelerated flow in the internal carotid artery on the left was iden-tified.
Cranial magnetic resonance imaging, including the soft tissues of the neck, was instigated immediately, and a hematoma on the wall of the internal carotid aorta was found on the left (arrow).This proved the initially suspected diagnosis of a dissection of the left internal carotid aorta. Luckily, no cerebral infarction was found.
The patient started treatment with phenprocoumon. Within a few weeks, the headache and the Horner syndrome completely disappea-red. Six months later, the patient's therapy was switched from phenpro-coumon to anticoagulant treatment with ASS 100 mg. At this point, the
