Updated: 6/7/2017

Headache

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  • A 33-year-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health until yesterday, when she experienced a pulsatile bilateral headache that caused her to have one episode of emesis. Her headache is accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable. (Migraine headaches)
Introduction
  • Headache is a common neurologic symptom that can be divided into
    • primary and secondary headache disorders
      • primary headaches include
        • tension-type headache
        • migraine headache
        • cluster headache
      • secondary headaches describe a headache caused by some other etiology such as
        • space occupying lesions
          • e.g., brain tumor, hematoma, and hydrocephalus
        • severe hypertension
        • cerebral venous thrombosis
        • pre-eclampsia
        • vasculitic syndromes
          • e.g., giant cell arteritis
        • head trauma
        • subarachnoid hemorrhage
        • infections
          • e.g., meningitis and encephalitis
  • Note that the brain parenchyma does not have pain receptors
    • therefore, pain leading to the headache is the result of
      • insults (e.g., inflammation or irritation) affecting innervated head structures such as the
        • meninges
        • scalp
        • skull
        • blood vessels
  • Warning signs for a secondary headache caused by a serious underlying etiology includes
    • systemic symptoms
      • e.g., weight loss, fever, and an immunocompromised state
    • neurologic symptoms
      • e.g., confusion, altered consciousness, papilledema, and focal neurologic deficits
    • onset of headache
      • new type or sudden headache
    • other
      • e.g., head trauma, illicit drug use, headaches that awakens the patient from sleep, headaches that worsens with valsalva maneuvers, and change in headache patterns
Primary Headache Disorders
 
Primary Headache Disorders
Headache Type
Clinical Features
Treatment
Tension-type headache
  • Bilateral headache described as a
    • "band-like"
    • non-throbbing
    • no associated features                                       
  • Duration
    • > 30 minutes
      • usually 4-6 hours
  • Abortive
    • NSAIDs
    • acetaminophen
  • Prophylactic
    • biofeedback and relaxation therapy
    • amitriptyline
Migraine headache
  • Unilateral (or bilateral) headache that is
    • throbbing or pulsatile
    • worse with activity
  • Can be associated with
    • photophobia
    • phonophobia
    • auras that can be
      • motor
      • sensory
      • visual
    • nausea and vomiting
  • Triggers
    • odors
    • lights
    • foods
    • weather
    • menses
  • Duration
    • 4-72 hours
  • Abortive
    • NSAIDs
    • acetaminophen
    • triptans
    • ergots
    • antiemetics
      • metoclopramide
      • chlorpromazine
      • prochlorperazine
  • Prophylactic
    • biofeedback and relaxation therapy
    • propranolol
    • valproic acid
    • calcium channel blockers
    • topiramate
    • amitriptyline
Cluster headache
  • Unilateral and repetitive stab-like periorbital headaches that are associated with
    • ipsilateral autonomic symptoms such as
      • lacrimation
      • rhinorrhea
      • Horner's syndrome
    • circadian periodicity
    • pain being severely debilitating
  • Duration
    • 15 minutes - 3 hours
  • Abortive
    • 100% oxygen
    • triptans
  • Prophylactic
    • verapamil
    • topiramate
 
Other Headaches
  • Trigeminal neuralgia (tic douloureux)
    • clinical definition
      • a headache disorder secondary to disruption of the
        • second (V2) and third (V3) branch of the trigeminal nerve
    • presentation
      • recurrent and brief episodes of pain most commonly in the distribution of V2 and/or V3
      • these headaches are often triggered by
        • chewing
        • shaving
        • touching or a breeze affecting the V2 and/or V3 distrubution
    • etiology
      • vascular compression
      • malignancy affecting the nerve
        • or any other cause such as
          • a plaque of multiple sclerosis
    • treatment
      • carbamazepine
      • oxcarbazepine
 
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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