NP Reasoning

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My Patient has a Headache, is Imaging Necessary?

Case: You’re seeing a 60-year-old female with intermittent headaches that have been getting progressively worse over the last two weeks. She has missed several days of work. “These are the worst headaches I have ever had!” You question whether this is a primary or secondary headache.

Primary versus Secondary Headache: A primary headache has no underlying sinister, structural, or systemic etiology, whereas a secondary headache is the result of another condition and warrants further investigation. The most common primary headaches include tension type headaches, migraine headaches, and cluster headaches. Less common include cerebral vasoconstriction syndrome, exertional headache, and primary cough headache (1).

Diagnostic Approach: Use the 5Ps (1)


Rule out Red Flags: Use SNOOP4 (1)

Back to the case: Using the 5Ps and SNOOP4 mnemonics to guide your history, you’re reassured that the headaches are not new, she does not have intermittent jaw claudication, temporal artery or scalp tenderness, and no focal neurological deficits on exam. However, two red flags include her older age with rapidly worsening headache frequency and intensity, which is a change to her usual pattern. Is imaging warranted?

Role for Imaging/Diagnostic Testing

Think about the specific diagnoses you want to rule out (1,2)

Back to the case: You have sufficient suspicion to rule out a mass lesion and decide to order a non-contrast CT head to start, and provide emergency department precautions in the meantime.

A note on the Canadian CT Head Injury/Trauma Rule: this is a validated clinical decision aid that allows clinicians to determine which minor head injury patients (GCS 13-15) need CT head imaging. This can be especially helpful in urgent care settings, check it out here


Key Take Home Points:

1. Use the 5Ps to guide your initial history and rule out red flags with SNOOP4. Using these mnemonics is a helpful diagnostic framework.

2. If you suspect primary headache but are not confident in your diagnosis, have the patient complete a headache diary and follow up. You can use this data to make a more confident primary headache diagnosis.

References/Readings

1. Ray JC, Hutton EJ. Imaging in headache disorders. Australian prescriber. 2022;45(3):88-92. (VIEW HERE)

2. Canadian Association of Radiologists. Canada. 2021-2022 [2022; June 25, 2023]. Available from: https://car.ca/patient-care/referral-guidelines/

 

Free Headache Diary Apps

1. Canadian Migraine Tracker

2. Migraine Buddy

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