Patient Introduction and Review of the Etiology of Headache

00:00 So, let's discuss a case of a patient with a headache. A 74-year-old woman presents to the emergency department after developing an intensely painful headache that has led to blurry vision and balance abnormalities. Now pretty much everybody has had a headache at some point in their lives, let's talk about some of the common types of causes of headaches. In general, we think about vascular causes, infectious, neoplastic, and idiopathic. Let's go through some examples of each. So let's start off by reviewing some vascular causes of headaches. Patients can present with a worst headache of life descriptor, also known as the thunderclap headache and that may be a harbinger of a subarachnoid hemorrhage which is certainly an emergent situation. In addition, patients can have either a hemorrhagic stroke or intracerebral hemorrhage or an ischemic stroke. If it's short-lived symptoms, we call that a transient ischemic attack or TIA or if there are sustained symptoms it's a cerebrovascular accident. In addition, there are infectious manifestations or infectious diseases that can cause headaches, sinusitis as in this example here with opacification of the left maxillary sinus or meningitis whether bacterial or viral classically presents with headaches and mental status changes. In terms of neoplastic causes of headache, the 2 broad categories are primary cancers and then tumors that have metastasized to the brain. Typically patients who do have brain tumors will present with morning headaches and possibly nausea and vomiting. This figure here highlights the fact that brain tumors can appear anywhere in the brain. Our physical exam is going to help us to hone in on where the abnormality is that would enable us to predict where we would find the lesion when we perform imaging if it's necessary.

01:52 And lastly, idiopathic headaches. The most common of which is tension headaches which are typically bandlike in distribution, cluster headaches which most often manifest with unilateral ice-pick like retro orbital pain. And then migraines which are also fantastically common, patients oftentimes report photophobia or phonophobia amongst other symptoms as well.

02:14 So going back to our patient, is this a cerebrovascular accident? Is it a TIA? Does this patient have meningitis? Or is this a more benign idiopathic headache? We'll need our physical exam to help to tease apart these different items on our differential diagnosis.