After spending 15 minutes or so reading through Reuben Strayer‘s how-to-present-to-him-as-a-med-student document (a systematic approach to the patient’s complaint, social situation, available resources, and physical exam), I went to see my first patient: a young woman with a headache. I don’t remember many of the details now–it struck me as a benign problem at the time–but after I finished presenting in said fashion, Reuben stopped, nodded, then said: “Ok. There are 13 dangerous causes of headache. Name them please.”
Like many dangerous chief complaints, the diagnosis does not always stick out as obvious. As a good reminder for July, a systematic approach (even if just a list of things to consider) for major chief complaints and presentations is essential to not miss the never-miss emergent diagnosis. A diagnosis of “migraine” or “tension headache” cannot be made without considering the other dangerous diagnoses first, unless (as Reuben notes) the presentation is entirely consistent with a previously established pattern for that patient.
Ruben’s list of 13 Dangerous Causes of Headache (and some associated things to consider):
| subarachnoid hemorrhage | family history, polycystic kidney disease, berry aneurysm, sudden onset, maximal at onset (or shortly thereafter), posterior headache |
| intracerebral hemorrhage | trauma, coagulopathy, decreased level of consciousness, hypertension |
| CNS infection | fever, immunocompromise, previous CNS instrumentation, recent head/face infection, meningismus |
| increased intracranial pressure | slowly progressive, cancer history, worse in morning, worse with head in dependent position, papillaedema (have you tried looking before?) |
| carbon monoxide toxicity | contacts with similar illness, worse in a specific location (like home or work) |
| acute angle closure glaucoma | unilateral anterior location, precipitated by darkness, change in vision, red eye |
| temporal (giant cell) arteritis | elderly, temporal location, jaw claudication, shoulder girdle symptoms |
| cervical artery dissection | unilateral pain involving neck/face, trauma history |
| cerebral venous sinus thrombosis | thrombophilia, neurologic signs/symptoms in non-arterial distribution, eyelid edema, proptosis |
| hypertensive encephalopathy | altered mentation, marked hypertension, improves with antihypertensive therapy |
| ENT/dental infection | ear, sinus, dental findings |
| idiopathic intracranial hypertension | young overweight female, hormone use, vision changes |
| preeclampsia | late pregnancy or postpartum |
