What is Wrong With Me, I Have a Big Headache? By Dr. Arthur M. Echano

Headache is one of the main reasons why people see their doctors. Locally, 15% take some form of pain killer at any given time. From the patient’s viewpoint though, killing the pain is just part of the agenda. He may also be interested to know what may be causing the pain. Which is understandable since some headaches may be due to injury, infection or tumour.
When patients see their doctors, they may get a bit impatient. Why so? Well, in the assessment of headache, their doctor may ask them so many questions. So what normally happens when a patient consult his doctor in his surgery? As the doctor may be as curious as the patient to know what is wrong with him so he can treat him promptly, he is going to follow the usual way in which any doctor diagnose a patient, by doing a thorough medical history.
If you have a headache and you want to help the doctor in his job of finding out what is wrong with you, be ready to answer a number of questions designed to zero in on the right diagnosis. Please remember that the more medical information the doctor extract from you, the better chances that he will hit bullseye as far as diagnosing your case. So what are some of these questions?
Your GP will start with asking for the onset of your headache, was it sudden or gradual in onset? Which part of the head is aching (e.g. front, back, around the head, the temple)? Is it one side only? How long have you been suffering from your headache? Is it constant or intermittent (on and off)?
How frequent is it? Does it radiate to your neck? How bad is it (mild, moderate or severe)? Normally, your GP will ask the severity of your headache on a scale of 1-10, with 1 as mild, 5 as medium and 10 as excruciating. How about the character or quality of the pain, is it dull, sharp, throbbing, stinging, deep aching? Are there triggers/aggravating factors and relieving factors?
He is not done with you yet. He will surely query about associated signs and symptoms that you are experiencing. What are some of these associated features of headache? Is there an aura (characteristic of classic migraine)? Did you feel nauseous? Is there any episode of vomiting? What about blurring of vision? Are you afraid of looking at the light? Do you have running nose or watery eyes? Is there any joint or muscle pain too? Can you move your neck freely? Is there a history of head trauma? What about abdominal pain or motion sickness?
You might wonder, why is he asking all of these questions? Why not just give me a script for pain killer and out I go? It is not as simple as that. Your GP would like to be sure that you don’t have any red flag or warning signal that may point to a more serious diagnosis. For example, if you tell him that you have a tightening headache around your head that radiates to your neck, not aggravated by your usual daily activities, last from minutes to days, he’ll be relieved since it looks like you just told him that you have tension headache. If you continue with your story that your headache is mild to moderate in intensity, is relieved by rest and is worse when you are anxious and with no vomiting or aura, he’ll be more convinced that it is indeed tension headache.
But what if you told him though that your headache is of recent onset and is accompanied by fever, drowsiness or confusion? Do you think your GP will still have the same sigh of relief? Not this time. The clinical features point to some sinister pictures like meningitis, encephalitis, brain abscess and severe high blood pressure. It is time to have a watchful eye with the strong possibility of sending the patient to the hospital for further assessment and management.
One question that many patients ask their doctor is about migraine. “Doctor, do I have migraine?” Before your GP gives you his answer, he will go through the same process of history taking. If there is someone in your family with migraine (mum, dad, siblings), if there is an aura (warning), if it is gradual in onset, throbbing in character, moderate to severe in intensity, last for hours to days, relieved by rest and aggravated by noise, light, straining, coughing and activity, the scenario favours a diagnosis of migraine.
Is the history enough though for your GP to make a diagnosis of migraine? He is close to it but to complete the picture, he has to try some medication first for migraine and if it works, then he can be confident to say that you do have migraine. What are some of these anti-migraine medications? GPs usually start with simple pain killers like aspirin and non-steroidal anti-inflammatory drugs. He may later change it to triptans and ergotamine if the simple pain medications are not working.
And if the migraine attacks are becoming more frequent to the point that it is affecting the patient’s daily life or school life for the younger ones, then it is time to think of giving some medications to prevent it from happening. The main prophylactic drugs that may be given to patients today are propranolol, tricyclic antidepressants and anti-convulsants.
We have so far mentioned tension and migraine headache. There is another popular member of the non-life threatening type of headache that may not be common but worthy of consideration since patients complain that when it strikes, the headache is severe. What is it? Have you heard of cluster headache? A cluster headache sufferer usually complains of pain behind one eye, last for minutes to about 2 hours, one-sided severe stabbing pain that wakes them up from sleep, is provoked by alcohol and light and relieved by walking around. It occurs in clusters and is associated with nasal congestion, red watery eye and droopy eyelid.
What is the treatment for cluster headache? For acute attacks, one may take the same medication that is given to someone with migraine- triptans. The only difference is that with cluster headache, only the nasal preparation or injection op triptan that works. If you give the patient the tablet form of triptan, he will continue to be in pain, with no relief at all. For prophylaxis (prevent the next attack), doctors may choose from steroids, lithium, verapamil or methylsergide.
After a focused and relevant history, your GP may do physical examination and investigations to make the final diagnosis. This is especially important when trying to rule out a life-threatening condition like meningitis, subarachnoid haemorrhage, giant cell arteritis or brain tumour. With meningitis for example, you might find a patient with fever who has stiff neck, photophobia (afraid of lights) and cranial nerves abnormalities.
If the physical signs are positive for meningitis (Kernig’s and Brudzinski) and the CT scan or lumbar tap findings are also pointing to meningitis, then prompt treatment is in order to prevent complications. I still remember a classmate of my younger brother who lost his eyesight in the mid-1960s due to bacterial meningitis. It probably started with a headache followed by fever, stiff neck and photophobia.
What can we learn from headache? We should not ignore it and assume that it is going to go away. Pain killers may remove the pain but it will never deal with the underlying cause of your headache. If you have headache that is recurrent, prolonged, severe and associated with fever, drowsiness, confusion, vomiting and other warning signs, see your doctor straight away. There is more to headache than just tension or migraine.

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  • Why Am I So Dizzy? By Dr. Arthur M. Echano

     

    Dizziness is one of the reasons a patient may see a doctor. The key to the determining what is causing it depends on good history taking. First things first though, a doctor has to make sure what the patient means by being dizzy since it can mean many things to many people.

    When we talk about dizziness, the first order of the day is to find out whether the source of the problem is from the inner ear or outside the inner ear. If it is coming from the inner ear, we call it vertigo. Outside of it, it could be either disequilibrium or presyncope/syncope.

    Let us exclude the last two first. Disequilibrium refers to a feeling of being off balance but there is no loss of consciousness or definite rotatory sensation. In presyncope/syncope, there is also no rotatory sensation but the patient feels loses consciousness. A person complaining of light headedness or having a “funny turn” could be having syncope. A fainting spell is a syncopal attack.

    Someone with funny turn has other possibilities aside from syncope. The patient could be suffering from sudden reduction of blood pressure when changing position (lying down to sitting, sitting to standing). This is called postural hypotension. It could also be due to a heart condition like irregular heart beat (arrhythmias), structural defect (aortic stenosis, mitral stenosis) and blood vessel abnormality (myocardial infarction, pulmonary embolism).

    Other conditions to consider when someone has a funny turn are mini-stroke (transient ischaemic attack), epilepsy, side effect of medications and low blood sugar (hypoglycaemia). As you may already notice, even with syncope alone, there are already few medical conditions that the doctor has to rule out to arrive at a reasonable diagnosis. Someone with recurrent or persistent dizzy spells needs to be investigated to find the root cause of the problem.

    How about disequilibrium, since the source of the problem is not from the inner ear, where may the doctor look? Dizziness due to disequilibrium could be from stroke involving the cerebellum or even brain tumour. So someone who has difficulty walking because of being off balance needs to see a doctor for proper assessment and management. Of course, if the patient is suffering from either stroke or brain tumour, you should expect other signs and symptoms like headache, slurring of speech, abnormal eye movements, paralysis in one side of the body and abnormal findings when doing cranial nerves examination. One thing to remember with stroke is that it usually occurs suddenly, not gradually. If the patient complains of weakness (paralysis) that took few days to develop, it is most likely secondary to a non-stroke nerve problem.

    Dizziness from the inner ear- vertigo is the kind of dizziness where the patient states that either s/he is rotating or the surrounding is spinning around. Consciousness level is preserved. In this category, there are four main medical conditions that the doctor will try to differentiate - vestibular neuronitis, benign paroxysmal positional vertigo, Meniere’s disease and recurrent vestibulopathy. So how do we know how to pinpoint the right diagnosis?

    Vestibular neuronitis (acute vestibular syndrome, vestibular neuritis, viral neuro-labyrinthitis) usually occurs suddenly, may last for many hours or even a day. The reason why it is also called viral neuro-labyrinthitis is due a history of viral illness. Those affected may have nausea and vomiting. Treatment is symptomatic, oral medications - Prochlorperazine and anti-histamines.

    The second condition in the vertigo list is benign paroxysmal positional vertigo. It occurs intermittently and is normally of short duration, lasting for a minute or less. As the name suggests, it is triggered by change of position, particularly head movement. It is self-limiting and resolves spontaneously. To elicit BPPV, the doctor performs the Hallpike maneuver and for treatment, s/he may do the Epley’s manuever.

    Epley’s manuever may be done at home. This manuever is given to us in detail from the British Medical Journal module on Vertigo:

    “*Explain the procedure to the patient, and warn them that they may experience vertigo symptoms during it, but that the symptoms usually subside quickly. Ask them to keep their eyes open throughout. Check that the patient does not have any neck injuries or other contraindications to rapid spinal movements - you need to execute movements during the procedure rapidly (in less than one second)

    *Ask the patient to sit on an exam couch with their legs extended, close enough to the edge so that their head will hang over the edge when they lie down

    *Stand on the side of the affected ear, take hold of the patient’s head with both of your hands, and turn their head 45° towards you. Hold until nystagmus dissipates

    *Keeping their head in that position, lean the patient back rapidly until their head is over the edge of the couch. Hold until nystagmus dissipates

    *Rotate the patient’s head through 90°, away from the side of the affected ear. Hold until nystagmus dissipates. Ideally, the patient’s head should be below the horizontal at all points when it is turned

    *Keeping their head steady with both of your hands, ask the patient to roll their body onto their side, away from the affected ear. While the patient is turning, turn their head a further 90°, so that it faces the floor. Hold until nystagmus dissipates

    *While keeping the patient’s head turned to the side, help them to sit up. Hold until nystagmus dissipates

    *With the patient sitting up, move their head into the centre line, as you move it forward 45° (chin on chest). Hold until nystagmus dissipates. “

    The 3rd one in our vertigo list is Meniere’s disease. The onset with Meniere’s disease is also intermittent, it may last for hours and is associated with deafness, ringing/buzzing in the ear (tinnitus) and feeling of fullness in the ear. While quite a few treatments have been tried with Meniere’s, none has been found to be truly effective. GPs end up referring these patients to ENT (ear, nose and throat) specialists for further management.

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