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

Serology: HIV, HZV, EBV, B. burgerdorfii, RPR and TPHA, mycoplasma, legionella

 

2-3x: 24-hour urine collection of catecholamines (VMA, dopamine, adrenaline, noradrenaline)

 

CSF

PCR for HZV, EBV, Tropheryma whippelii

Ophthalmology

Kayser-Fleischer ring

Imaging

Brain MRA, MRV

Echography abdomen, 123I-metaiodobenzylguanidine scan, MRI abdomen.

Neurophysiology

ECG, echocardiography

SSEP, VEP

Biopsy

Genetic testing

 

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