ANSWER 48
This patient has a chronic tension headache. This is the commonest form of headache. It
occurs mainly in patients under the age of 50 years. The headache is usually bilateral, often
with diffuse radiation over the vertex of the skull, although it may be more localized. The
pain is often characterized as a sense of pressure on the head. Visual symptoms and vomit-
ing do not occur. The pain is often at its worst in the evening. Patients may show symp-
toms of depression (this woman has biological symptoms of loss of appetite and disturbed
sleep pattern). Sufferers may reveal sources of stress such as bereavement or difficulty with
work. There may be an element of suggestion as in this case, with concern that she may
have inherited a brain tumour from her mother. She is looking after two children alone and
working part-time. A normal neurological examination is important for reassurance.
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- Classic migraine: characterized by visual symptoms followed within 30 min by the
onset of severe hemicranial throbbing, headache, photophobia, nausea and
vomiting lasting for several hours. The onset is usually in early adult life and a
positive family history may be present. - Cluster headaches: mainly affect men. The pain is unilateral, usually orbital and
severe in nature. It characteristically occurs 1–2 h after sleeping, and lasts 1–2 h and
recurs nightly for 6–8 weeks. - Headache caused by a space-occupying lesion(such as tumour or abscess): Often
the headache is initially mild but over a few weeks becomes severe and is
exacerbated by coughing or sneezing. The headache is usually worse in the
morning and is associated with vomiting. There will often be other signs, including
personality change and focal neurological signs. - Miscellaneous causes: sinusitis, dental disorders, cervical spondylosis, glaucoma,
post-traumatic headache.
Major differential diagnoses of chronic headachesIt is important to come to a clear diagnosis and to address the patient’s beliefs and con-
cerns about the symptoms. In some circumstances it may be necessary to perform a com-
puted tomography (CT) head scan for reassurance. The question of depression needs to be
explored further and may need treating with antidepressants.
- Tension headaches occur mainly in those aged under 50, and patients often show fea-
tures of depression. - Tension headache should be diagnosed after other causes have been excluded.