2. Headache: When to see a physician Morris Levin, MD Section of Neurology Dartmouth Medical School

3. Head Pain - sources Meninges Brain veins and arteries Pain nerves Periosteum Scalp Scalp muscles Scalp blood vessels Sinuses Eyes Ears Teeth, TMJ Arteries of the neck Neck spine Neck muscles

4. IHS Classification - 2003 IHS Primary HA 1. Migraine 2. Tension-type 3. Cluster 4. Exertional Secondary HA 5. Post-traumatic 6. Blood vessel disease 7. Brain tumor 8. Substances 9. Infection 10. Medical problems 11. Neck, Eyes, SInuses 12. Psychiatric 13. Neuralgias

5. Primary Headaches Migraine –severe, one-sided, –nausea Tension-Type –milder, more diffuse, – –no nauseaCluster –brief, around the eye, –occurs in cycles

6. Warning Signs in Headache Warning Signs in Headache  Sudden  Brought on by exertion  New kind of headache, or change in pattern  Onset in middle age or later  Fever  Change in behavior or thinking  Changes in sensation, strength  Setting of systemic disease - eg Cancer, AIDS

7. Medical Evaluation of Headaches History of the HA problem General medical history General examination Diagnostic testing

8. Medical Evaluation History –Where, When –What Triggers, what helps –What other symptoms –Family history –Medical problems and medications

9. Medical Evaluation Examination –Head and Neck –General exam –Neurological exam Mental function Vision Motor function SensationCoordination

10. Options: Blood tests X-rays MRI, CT Lumbar Puncture Testing Testing Medical Evaluation MRI

11. Brain Tumors and HA 50% of Brain neoplasms present with HA <.1% of HA sufferers have brain neoplasm

12. Vascular problems Arteriovenous malformation aneurysm

13. Infections Brain abscess Cysticercosis

14. IHS Classification - 2003 IHS Primary HA 1. Migraine 2. Tension-type 3. Cluster 4. Exertional Secondary HA 5. Post-traumatic 6. Blood vessel disease 7. Brain tumor 8. Substances 9. Infection 10. Medical problems 11. Neck, Eyes, SInuses 12. Psychiatric 13. Neuralgias However – Recurring headaches are usually primary (migraine or tension-type headache)

15. Headache - When to see a Physician Conclusions Headache can be a warning sign of serious illness Most correctable causes of headache can be found Most headache problems are due to “primary headache”