Headache is a pain in any part of the head, incl. Scalp, face (including orbitotemporaler area) and the interior of the head. Headache is one of the most common reasons why patients seek medical help. Pathophysiology headache is due to the activation of pain-sensitive structures in or near the brain, skull, face, sinuses or teeth. Etiology headache can occur as a primary disorder, or be derived from another disease. The primary headache disorders include migraine cluster headache (including chronic paroxysmal hemicrania, hemicrania continua, and short-lived, one-sided neuralgic headache with conjunctival injection and Abreissen- sometimes collectively called trigeminal autonomic cephalalgia) tension headache Secondary headache has numerous causes (see Table: Diseases , the secondary cause headache). Overall, the most common causes of headaches are tension headaches migraine headache Some causes are common; others must be recognized necessarily because they are dangerous and / or specific treatment require (see table: headache characteristics, broken down by cause). Diseases secondary headache cause CAUSE examples Extracranial disorders carotid or Vertebralarteriendissektion (also cause neck pain) Zanherkrankungen (z. B. infections, temporomandibular joint dysfunction) glaucoma sinusitis Intracranial disease brain tumors and other masses Chiari malformation type I headache liquor hypotension by CSF leakage bleeding (intracerebral , subdural, subarachnoid) idiopathic intracranial hypertension infections (z. B. abscess, encephalitis, meningitis, Subduralempyem) Non-infectious meningitis (eg. B. conditionally (by a cancer caused by chemicals) obstructive hydrocephalus vascular z. B. vascular malformations, vasculitis, venous sinus thrombosis) Systemic diseases Acute severe hypertension bacteremia fever giant hypercapnia hypoxia (incl. Altitude sickness) virus infection viremia drugs / medicines and toxins Excessive analgesics use caffeine withdrawal monoxide hormones (z. B. estrogen) nitrates proton pump inhibitor headache characteristics, classified according to the cause Cause may be easy on the fault findings diagnostic approach Primary headache disorders * cluster headache Unilateral orbitotemporale pain attacks, often at the same time of day deep, strong, duration 30-180 min Often with lacrimation, facial flushing or Horner’s syndrome; Restlessness Clinical evaluation migraine headache often one-sided and pulsating period 4-72 h Occasionally with aura In general, with aura, nausea, photophobia, phonophobia or aversion to odors aggravation in activity, preferably in the dark, relieving in the sleeping Clinical evaluation tension headache Frequent or constant , lighter, bilateral and vise-like occipital or frontal pain that spreads over the entire head aggravation towards the end of the day Clinical evaluation Secondary headache Acute angle-closure glaucoma sided frontal or orbital halos around lights, decreased visual acuity, conjunctival injection, vomiting tonometry altitude sickness dizziness, loss of appetite, nausea, vomiting, fatigue, irritability, sleep disturbances in patients recently on high altitude event that during (including flight ? 6 h Clinical in an airplane) investigation encephalitis fever, altered mental status, seizures, focal neurological deficits MRI, CSF analysis giant Age> 55 years sided throbbing pain, pain when combing hair, blurred vision, jaw Klaudikatio, fever, weight loss, sweating, sensitivity of the temporal artery, proximal myalgia erythrocyte sedimentation rate, biopsy of the temporal artery, Idiopathic usually neuroradiological imaging intracranial hypertension migraine-like headache , double images, pulsatile tinnitus, peripheral visual field loss, papilledema neuroradiological imaging (MRI preferably with magnetic resonance venography), then measuring the Liquoröffnungsdrucks and cell count Culture and analysis. Intracerebral hemorrhage Sudden onset vomiting, focal neurological deficits, altered mental status Neuroimaging medication overuse headache headache with variable position and intensity presence> 15 days / mo often present upon awakening develops typically after excessive use of analgesics that have been taken for an episodic headache disorder. Clinical examination meningitis fever, neck stiffness, altered consciousness CSF analysis, previously often CT post-dural-puncture headache and vacuum Headache Intense headaches, often with neck stiffness and / or vomiting worse sitting or standing, leaving only when lying flat after. Clinical examination sinusitis Localized facial or dental pain, fever, purulent rhinitis clinical evaluation, sometimes CT subarachnoid hemorrhage Highest intensity a few seconds after the start of the headache ( “thunderclap headache”) vomiting, syncope, depressed consciousness, neck stiffness Neuroimaging, then Liquroanalyse if that is contraindicated imaging is not diagnostic subdural hematoma (chronic) drowsiness, changes in consciousness, hemiparesis, lack of spontaneous n venous pulsations, papilledema presence of risk factors (eg. As older age, coagulopathy, dementia, use of anticoagulants, alcohol abuse) Neuroimaging A tumor or lesion in the course altered mental status, seizures, vomiting, double vision during lateral viewing direction, Neuroradiological lack of spontaneous venous pulsations or papilledema, focal neurological deficits imaging * Primary headache is recurring normally. Clarification evaluation of headaches focuses on the determination of whether a secondary headache is present check for symptoms that suggest a serious cause If no cause or serious symptoms are identified, the investigation focused on the diagnosis of primary headache. The history of the medical history includes questions regarding. Localization, duration, severity, beginning (z. B. suddenly, gradually) and quality (eg. As throbbing, permanent, intermittent, pressure-like) of the headache. Aggravating and ameliorating factors (z. B. head position, daytime, sleep, light, sound, physical activity, odors, chewing) are added. If the patient already have had headaches or suffer from recurrent headaches that earlier diagnosis must (if any) are resolved and determined whether the current headache is the same or different. For recurring headaches the age of onset, frequency of episodes, temporal patterns (incl. Possible links with the phase of the menstrual cycle), and the response will be documented on treatments (incl. Treatment with over the counter preparations). Blur infection (eg encephalitis, meningitis, sinusitis.) Red eyes and / or visual symptoms (halos: In reviewing the organ systems should after symptoms are searched, which point to a cause, including vomiting: migraine or increased intracranial pressure fever ): Acute angle-closure glaucoma visual field defects, diplopia or blurred vision: Eye migraine lesion by lesion in the brain or idiopathic intracranial hypertension tearing and facial flushing: cluster headache rhinorrhea: sinusitis Pulsatile tinnitus: idiopathic intracranial hypertension Preliminary aura: migraine Focal neurological deficit: encephalitis, meningitis, cerebral hemorrhage, subdural hematoma, tumor or other lesion seizures: encephalitis, tumor or other lesion Syncope in headache Starting subarachnoid hemorrhage myalgia and / or symptoms (in persons> 55 years): giant in the medical history should be identified risk factors for headaches, including exposure to drugs / drugs, substances (v.. a. Caffeine) and toxins (see Table: Diseases that cause secondary headaches), recent lumbar puncture, immunosuppressive disorders or i.v. drug use (risk of infection); Hypertension (risk of cerebral hemorrhage); Cancer (risk of brain metastases) and dementia, trauma, bleeding disorders or use of anticoagulants or alcohol (risk of subdural hematoma). Family and social history should include any family history of headaches, particularly because migraine headache can not be diagnosed in family members. To optimize data collection, doctors can ask patients to fill out a headache questionnaire that covers the majority of relevant medical history that is relevant to the diagnosis of headache. (Editor’s note: A similar questionnaire in Germany is not available Rather, the patient will carry a so-called Headache Diary usually dependent For Germany see also:…. http://www.schmerzklinik.de/wp-content/uploads/2009 /02/kieler-migrane-und-kopfschmerzfragebogen.pdf.) patients can complete the questionnaire before their visit to the doctor and the results mitbringen.Körperliche examination Vital signs, incl. temperature are detected. The general appearance (eg. As the patient is in a dark room restless or calm) is noted. A general study focusing on the head and neck and a full neurological examination be performed. The scalp is examined for swollen and sensitive areas. The ipsilateral temporal artery is sampled, and both temporomandibular joints are palpated on sensitivity and crepitation, while the patient opens the jaw and closes. The eyes and eye area are inspected for tearing, redness and conjunctival injection. Pupil size and reaction to light, extraocular movements and visual fields are evaluated. The Fundi be checked for spontaneous venous pulsations and papilledema. If the patient regarding symptoms. The have vision or abnormalities of the eyes, visual acuity is determined. For reddened conjunctiva, the anterior chamber and the cornea to be examined as possible, with a slit lamp, and the intraocular pressure is measured. The nostrils are inspected facilities. The mouth and throat is checked for swelling and knocked the teeth sensitivity. The neck is rotated to detect discomfort and / or stiffness, indicating a meningism. The cervical spine is palpiert.Warnzeichen on Sensitivity The following results are of particular importance: neurological symptoms or signs (. Eg consciousness changes, weakness, diplopia, papilledema, focal neurologic deficits) immunosuppression or cancer meningism beginning of the headache after the age of 50. ” thunderclap headache “(severe headache which reaches its climax in a matter of seconds) symptoms of giant cell arteritis (z. B. blurred vision, jaw Klaudikatio, fever, weight loss, sensitivity of the temporal artery, proximal myalgia) Systemic symptoms (eg. as fever, weight loss) gradual deterioration of headaches Red eyes and halos around lights interpretation of the findings When similar headache in patients who are doing well, he appear and have a normal examination, recur, the cause is rarely threatening. Headaches that have occurred repeatedly since childhood or young adulthood, point to a primary headache disorder. to headache type or pattern change significantly in patients with a known primary headache disorder, secondary headaches should be considered. Most of the single symptoms of primary headache disorders, with the exception of the aura, nonspecific. A combination of symptoms and signs is more characteristic (see Table: headache characteristics, divided into the cause). Findings with warning signs speak (see table: compliance of findings with warning signs and causes of headache) for a cause. Conformity of reports with warning signs and causes of headache may be easy on the fault findings causes neurological symptoms or signs (eg. As altered consciousness, confusion, neurogenic weakness, diplopia, papilledema, focal neurologic deficits) encephalitis, subdural hematoma, subarachnoid hemorrhage or cerebral hemorrhage, tumor, other intracranial lesions , increased intracranial pressure immunosuppression or cancer, CNS infection, metastasis meningism Meningitis, subarachnoid hemorrhage, Subduralempyem beginning of headaches after age 50 increased risk for a serious cause (eg. As tumor, giant cell arteritis) “thunderclap headache” (strong headache within seconds its peak reached) subarachnoid hemorrhage combination of fever, weight loss, blurred vision, jaw Klaudikatio, sensitivity of the temporal artery and proximal myalgia giant Systemic symptoms (eg. As fever, weight loss) sepsis, hyperthyroidism, cancer Gradual worsening of headaches Secondary headaches Red eyes and halos around lights Acute angle-closure glaucoma studies In most patients can be diagnosed without performing tests. However, some serious disease may require urgent or immediate investigation. Some patients need the investigations as soon as possible. A CT (or MRI) is as fast as possible with one of the following findings conducted in patients. “Thunderclap headache” consciousness changes meningism papilledema signs of sepsis (. Eg rash, shock) Acute focal neurological deficits Severe hypertension (eg systolic > 220 mmHg or diastolic> 120 mmHg in successive discharges) in V. a. Meningitis, subarachnoid hemorrhage, or encephalitis should have a lumbar puncture and CSF analysis are carried out in addition, unless this is contra-indicated by the results of imaging. Patients with a “thunderclap headache” need a Liquroanalyse, even if the CT and examination findings are normal, as long as a lumbar puncture explains the results of imaging is not contraindicated. A tonometry is performed when speak the findings of acute narrow-angle glaucoma (z. B. visual halos, nausea, corneal edema, flat anterior chamber). Further studies should be conducted within hours or days depending on the acuteness and severity of the findings and the suspected causes. A neuro-radiological imaging, mostly MRI should be done when the patient one of the following characteristics: Focal neurologic deficit with subacute or shaky start Age> 50 years weight loss cancer HIV infection or AIDS change in an established headache pattern diplopia The erythrocyte sedimentation rate should be determined at patients with visual symptoms, jaw or tongue Klaudikatio, symptoms of temporal artery or other findings that suggest a giant. A CT scan of the sinuses is performed to rule out a complicated sinusitis, if patients have a moderately severe systemic disease (eg. As a high fever, dehydration, fatigue, tachycardia) and findings have that speak for sinusitis (z. B. frontal, limited headache; nasal bleeding, purulent rhinitis). Lumbar puncture and CSF analysis should be carried out when the headache progresses and the findings idiopathic intracranial hypertension (z. B. transient obscuration of sight, diplopia, pulsatile intracranial tinnitus) or chronic meningitis (eg. As persistent low-grade fever, cranial neuropathy, cognitive impairment, lethargy, vomiting) suggest. Treatment The treatment of headache is focused on the cause. Geriatric fundamentals Emerging headache after age 50 should be considered as a secondary disorder until proven otherwise. Conclusion Recurring headaches that have begun in patients with a normal examination at a young age, are usually benign. Neuroimaging is, focal neurological deficits or “thunderclap headache” recommended in patients with altered mental status, seizures, papilledema as early as possible. A CSF analysis is usually required in patients with neck stiffness and following a neuroradiological imaging in immunocompromised patients. Patients with “thunderclap headache” need a Liquroanalyse, even if the CT and examination findings are normal.