HEADACHES: DIAGNOSIS

‘Diagnose first, treat second.’ This statement may appear obvious, but it’s very easy to make the mistake of treating symptoms (such as pain or nausea) without getting to the root of the condition or disease causing the symptoms. Treatment is much more effective if there is an accurate initial diagnosis!

It’s all too easy to treat a headache with a couple of aspirins, without stopping to think why that headache is occurring. Then, when the headache doesn’t go away, you can’t help but wonder if you should increase the dose … and then you’ve fallen neatly into the trap. Diagnose first, treat second means that you stop to think before you reach for those painkillers, even on the first occasion.

However, diagnosing the cause of your headache may not always be easy, because there can be so much overlap between symptoms. For example, headaches caused by neck problems can sometimes imitate a migraine; temporal arteritis (an inflammation of the arteries in the forehead) can produce a headache similar to one that has arisen from tension; and arthritis in the neck can mimic tension headaches. Unfortunately, there are few hard and fast diagnostic rules: knowing the site or type of pain may not be enough to tell you its cause. Accurate diagnosis of the source of your headaches will probably depend not upon one specific symptom, but on carefully balancing the importance of a number of different symptoms and observations.

Here lies a trap for the amateur doctor! When reading a medical book like this, it’s all too easy to come up with the worst possible diagnosis, and then force your own symptoms to fit it. This is the ‘medical student syndrome’. When medical students start to learn about disease they often try to self-diagnose their own aches and pains — usually with disastrous results. Every medical school health centre has a constant trickle of students who have convinced themselves (usually erroneously) that they are about to die from some dreadful disease.

Nevertheless, do make sure that you consult your doctor about your fears. He will be able to see things in a much more balanced light. It is, of course, possible that you are right in your suspicions — but the vast probability is that you won’t be, so don’t worry unnecessarily.

The last thing you should do is use this book in isolation, self-diagnosing your own headaches and then blithely self-medicating yourself. If you’re having trouble with headaches and you haven’t been to your doctor, then make an appointment, discuss your problems and ask for advice. By all means use this book to point yourself in the right direction. And if you’re worried that you have a particular disease, do specifically mention it to your doctor. Once you have discussed the situation and, if necessary, had an examination, listen to the diagnosis and take note of the advice. Doctors have the knowledge, the experience and the objectivity to treat you properly. It’s hard to be objective when the patient is yourself!

So let’s get down to working out what might be the underlying cause of your particular headache.

Although the site of the pain and its pattern can often point to a particular diagnosis, in practice it doesn’t always work out that way; the same source of headache doesn’t produce identical types of pain in everyone. For example, tension headaches often produce pain in the forehead, or a feeling of pressure over the top of the skull. On the other hand, some muscle-tension headaches can produce pain centring over one eye (a type of pain which is more usually associated with migraine). So how do you know which is which?

Because headaches can be so variable there is no one symptom which allows us to make a firm diagnosis. Instead, it’s a matter of finding the pattern of illness which seems to fit most of the facts. The type of pain may point towards two or three possible diagnoses; the time it comes on may point to a slightly different set of possibilities; the things that start it off, to a third group of alternatives; and the accompanying symptoms to a fourth.; put them all together and you may find a single diagnosis which is common to all these groups, and it is this diagnosis which should be top of your list of possible causes.

Obviously, it’s nice if everything points in the same direction — and doctors do like to try to make one diagnosis which covers all the symptoms. On the other hand, this isn’t always possible in the case of headaches.

Because the symptoms of headaches are so variable, rather than producing just one flow chart to identify the cause of your headaches, I’ve created several diagnostic charts and lists. Work through them one after the other. If you get some common answers then you’re probably heading in the right direction. On the other hand, if you get a group of different possibilities it can mean one of several things:

•    Perhaps the source of your headache is producing symptoms in a less common way

•    Maybe you’ve got more than one cause for your headache

•    The possible causes of your headache may need to be sorted out by doing some special tests, for which you will need to see your doctor.

Armed with your answers, consult the relevant chapter of this book, describing the causes of headaches in much greater detail. You may well find that this extra detail allows you to pinpoint the cause of your headache more accurately.

But what if you can’t? Well, don’t forget that several causes of headache can be operating at the same time. Be prepared to have one main diagnosis and one (or even two) secondary diagnoses. It’s quite common to find that causes of headaches multiply together — so a patient whose headaches are caused mainly by arthritis of the neck may also find her headaches are made worse by stress and tension; migraine and tension headaches often work together in this way, too; and someone with high blood pressure may also, quite coincidentally, have a bad neck from an old whiplash accident.

But diagnosis doesn’t stop here. There is a further diagnostic tool: if the treatment works it confirms the diagnosis. (That is assuming, of course, that the treatment is not a catch-all method such as taking high doses of painkillers.) Similarly, if a specific treatment doesn’t work, it may mean that the diagnosis is not as accurate as you supposed. However, this advice needs to be handled with care, because people don’t always respond to the same treatment in the same way. For example, many migraine sufferers find great relief by using metoclopramide (together with a simple painkiller); others find this of no help at all, and prefer one of the ergotamine preparations. The response to treatment can help us to confirm the diagnosis, but it isn’t always specific.

To sum up, try to look at the overall picture and see where it all leads -symptoms, signs, tests and response to treatment. If the majority of answers point in the same direction, you should look up the details of this illness; only if you find no clear answers should you look at the alternatives.

*2/20/2*

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