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Headache is one of the most commonly encountered problems in the clinical medicine. Acute and chronic headaches are very common symptoms that may result from a variety of causes, often classified as primary (e.g., migraine, tension) or secondary (e.g., brain tumor, stroke, trauma).

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with HEADACHE can include:

Medical Knowledge Learning Topics related to HEADACHE:

1. Clinical features that help to differentiate one etiology from another:
2. Signs and symptoms that suggest malignant etiology, such as “red flags” listed below:

  • new headache
  • “the worst headache”
  • abrupt onset
  • change in the pattern
  • fever
  • stiff neck
  • headache precipitated by Valsalva (coughing, laughing, or sneezing)
  • onset after age 50 years
  • weight loss
  • neurological focal signs
  • decreased mental status
  • papilledema
  • crescendo pattern(s)
  • headache that awakens the patient from sleep
  • after head or neck injury
  • jaw claudication
  • association with severe hypertension
  • association with numb chin or cheek
  • history of cancer
  • history of immunosuppression
  • poor response to therapy
  • worsening with orthostatic challenge
  • unilateral
  • scalp tenderness
  • monocular visual loss

3. Headache symptoms, signs, or other patterns that suggest an underlying etiology, such as:

  • increased intracranial pressure: positional, aggravated by Valsalva
  • decreased intracranial pressure: aggravated by gravitational challenge or spontaneous onset
  • intracranial tumor: progressive, focal neurological signs
  • pseudotumor cerebri: obscurations, associations with demographic factors (i.e., obesity, female sex, fertility, over age of 40)
  • venous thrombosis: child-bearing age, dehydration, trauma
  • meningitis (including infectious or non-infectious causes): meningeal signs, fever
  • chronic daily headache: caffeine use; rebound headache: NSAIDs, triptans, opiates or other chronic medications
  • sleep apnea: snoring, daytime sleepiness, symptoms present even when “sleeping in”
  • recurrent headache: migraine, cluster, paroxysmal hemicrania

4. Risk factors associated with headache
5. Laboratory studies and their role in the evaluation of headache, including indications, limitations, and cost
6. Imaging studies and their role the evaluation of headache, including their indications, limitations, and cost

Diagnostic Evaluation Learning Topics related to HEADACHE

1. Age-appropriate medical history taking, documentation, and presentation that differentiates among etiologies of disease
2. Physical examination, including mental status examination as well as a screening and targeted neurological examination to establish the diagnosis and severity of disease
3. Differential diagnosis generation recognizing specific history and physical exam findings that distinguish causes of headache
4. Diagnostic and laboratory testing necessary to determine the cause of the disease, including indication, interpretation both prior to and after initiating treatment based on the differential diagnosis, and in the context of test performance, cost, and patient preferences
5. Indications for and interpretation of (with consultation) appropriate clinical tests
6. Basic clinical diagnostic procedures

Management Plan Learning Topics related to HEADACHE:

1. Indications, mechanism of action, side effects, adverse reactions, significant interactions with other medications, and overall benefits and disadvantages of medications that could be prescribed for patients with headache
2. Cost-effectiveness of various agents within each class of medications, such as:

  • Abortive therapies: NSAIDs, triptans, DHE, IV magnesium, IV valproic acid
  • Prophylactic therapies: amitriptyline, beta-blockers, topiramate, verapamil

3. Non-pharmacologic approaches and potential lifestyle changes
5. Treatment planning for the patient with headache based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences
6. Prognostic formulation for the patient with headache based on the diagnosis, the treatment plan, and the patient’s characteristics
7. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and the impact on the patient’s daily activities and lifestyle
8. Patient education for the patient with primary headache regarding goals and treatment plan, which may include:

  • Reassurance,
  • Target identification and avoidance
  • Dietary counseling
  • Sleep hygiene
  • Smoking cessation
  • Stress management
  • Exercise recommendations
  • Timing of treatment (e.g., treat as early as possible)
  • Avoidance of opioid medications
  • Appropriate use of abortive therapy.
  • Use of prophylactic medications (e.g., initiation, titration, target goals)

9. Prevention counseling when indicated
10. Psychological support referral, if indicated
11. The use of appropriate information systems to ascertain information about health system and community resources
12. Follow-up planning

Potential Differential Diagnosis Topics Include:

  • infectious etiologies (e.g., meningitis, encephalitis)
  • oncologic etiologies (e.g., brain tumor)
  • medications (e.g., medication rebound headache)
  • vascular etiologies (e.g., stroke, vasculitis, temporal arteritis)
  • ENT sources
  • dental sources
  • neurologic etiologies (e.g., migraine, cluster headache)
  • sleep disorders (e.g., sleep apnea, bruxism)
  • other causes (e.g., tension headache, low CSF pressure)