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
May 2024