A 50-year-old previously well gentleman presents to you with x3/52 ho headache. On further questioning he admits to being under a lot of stress at work lately.
Question 1: How would you approach and manage this patient?
Question 2: What are your differential diagnoses?
Question 3: How do you confirm or rule out the possibility of depression as the cause of headache?
Question 4: What are the red flags in headache?
Drug Discussion: What are the medications used to treat tension headache? What are the medications' mode of action and common side effects?
Salam.....
ReplyDeletequestion 1 : firstly, i would like to introduce myself and my role..then ask about patient's details like name,age and occupation. then ask the reason of the patient come to the clinic today..about the headache, i would like to know the details such as the site, onset, characteristic of the pain, if there is any radiation, any associated symptom, the duration of the pain and the aggravating and relieving factor.after that, ask specific question to exclude the most serious condition to the least serious. then continue to PMH,social history, drug history.
question 2 : differential diagnosis include space occupying lesion at the brain,CNS infection,migraine, tension type headache,and depression.
q3 : to rule out depression, ask question such as how do u feel about life, how's work, do u ever think of committing suicide, do u feel any hope for the future...if the patient respond to the question, he might have depression.
q4 : red flag in headache include sudden onset headache,severe and debilitating pain, fever, vomitting, disturbed consciousness, worse with bending or coughing, maximum in morning, any neurological sign, young obese female and elderly. but i dont know why we need to ask whether it is worse with bending or coughing.
Studies show that 74 percent of people seeking help for depression go to their primary care physician, and that 50 percent of these cases are misdiagnosed. Of the cases that are correctly diagnosed by a general practitioner, 80 percent are given too little medication for too short a time. Some of this mishandling may occur because the patients are treated for physical symptoms, such as sleep problems, fatigue or weight loss, without considering depression as a possible root cause. When diagnosing for depression, tests should be given to rule out any organic factors - such as nutrient deficiencies, hypothyroidism, reactions to drugs - that can produce similar symptoms. And here are the steps to do a correct diagnosis:
ReplyDeleteAccording to DSM-IV, the diagnostic manual from American Psychiatric Association, criteria used by mental health professionals, you have Major Depressive Disorder if:
You have had an episode of depression lasting at least two weeks with at least five of the following symptoms:
(1) You are depressed, sad, blue, tearful.
(2) You have lost interest or pleasure in things you previously liked to do.
(3) Your appetite is much less or much greater than usual and you have lost or gained weight.
(4) You have a lot of trouble sleeping or sleep too much.
(5) You are so agitated, restless, or slowed down that others have begun to notice.
(6) You are tired and have no energy.
(7) You feel worthless or excessively guilty about things you have done or not done.
(8) You have trouble concentrating, thinking clearly, or making decisions.
(9) You feel you would be better off dead or have thoughts about killing yourself.
These symptoms are severe enough to upset your daily routine, or to seriously impair your work, or to interfere with your relationships.
The depression does not have a specific cause like alcohol, drugs, medication side effect, or physical illness.
Your depression is not just a normal reaction to the death of a loved one.
It is important to recognize that most of us go through ups and downs in our life periodically, as a result of events such as death of a loved one, loss of a job, serious illnesses in the family, etc. These are not signs of clinical depression as we get out of them in a short period of time and spring back to our normal activities. The clinical depression is characterized by persistent depression. At least 5 of the above conditions have to be satisfied to be classified as major depression. It is important for you to recognize the signs of the illness that requires treatment as opposed to occasional "blues."
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ReplyDeleteIts good that you start you history taking with an introduction and clirifying the patient's identity followed by open ended questions. As you ask the relevant questions of headache (site, onset...) you should be thinking about the differential diagnosis as you go along. Your differential diagnosis is incomplete. In primary care anything is possible so you must include ALL of the causes of headache in your differentials. You can start listing the causes of headache with the most common to uncommon ones or from top to toe or arrange the differentials according to systems (CVS, RS, CNS) or divide it into metabolic/ endocrine, infections/ drugs/ psychological, or may combine all theses methods. Go to this website for more details on headaches.
ReplyDeletehttp://www.aafp.org/afp/2001/0215/p685.html
Headache "Red Flags"
"Red flags" for the presence of serious underlying disorders as a cause of acute or subacute headache can be remembered by using the mnemonic SNOOP:
Systemic symptoms or illness (including fever, persistent or progressive vomiting, stiff neck, pregnancy, cancer, immunocompromised state, anticoagulated);
Neurologic signs or symptoms (including altered mental status, focal neurologic symptoms or signs, seizures, or papilledema);
Onset is new (especially in those age 40 years or older) or sudden;
Other associated conditions (eg, headache is subsequent to head trauma, awakens patient from sleep, or is worsened by Valsalva maneuvers);
Prior headache history that is different (eg, headaches now are of different pattern or are rapidly progressive in severity or frequency).
When such red flags are present, neuroimaging (computed tomography [CT] or MRI) is indicated to investigate secondary causes of headache.
*Headache worst on bending or coughing (valsalva manouveres) indicates raised ICP.