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Chapter 015. Headache (Part 2) Clinical Evaluation of Acute, New-Onset Headache The patient who presents with a new, severe headache has a differential diagnosis that is quite different from the patient with recurrent headaches over many years. In new-onset and severe headache, the probability of finding a potentially serious cause is considerably greater than in recurrent headache. Patients with recent onset of pain require prompt evaluation and often treatment. Serious causes to be considered include meningitis, subarachnoid hemorrhage, epidural or subdural hematoma, glaucoma, and purulent sinusitis. When worrisome symptoms and signs are present (Table 15-2), rapid diagnosis and management is critical. Table 15-2. | Chapter 015. Headache Part 2 Clinical Evaluation of Acute New-Onset Headache The patient who presents with a new severe headache has a differential diagnosis that is quite different from the patient with recurrent headaches over many years. In new-onset and severe headache the probability of finding a potentially serious cause is considerably greater than in recurrent headache. Patients with recent onset of pain require prompt evaluation and often treatment. Serious causes to be considered include meningitis subarachnoid hemorrhage epidural or subdural hematoma glaucoma and purulent sinusitis. When worrisome symptoms and signs are present Table 15-2 rapid diagnosis and management is critical. Table 15-2 Headache Symptoms that Suggest a Serious Underlying Disorder Worst headache ever First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting that precedes headache Pain induced by bending lifting cough Pain that disturbs sleep or presents immediately upon awakening Known systemic illness Onset after age 55 Pain associated with local tenderness e.g. region of temporal artery A complete neurologic examination is an essential first step in the evaluation. In most cases patients with an abnormal examination or a history of recent-onset headache should be evaluated by a CT or MRI study. As an initial screening procedure for intracranial pathology in this setting CT and MRI methods appear to be equally sensitive. In some circumstances a lumbar puncture LP is also required unless a benign etiology can be otherwise established. A general evaluation of acute headache might include the investigation of cardiovascular and renal status by blood pressure monitoring and urine examination eyes by fundoscopy intraocular pressure measurement and refraction cranial arteries by palpation and cervical spine by the effect of passive movement of the head and by imaging. The psychological state of the patient .
