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Decades ago, it was called “trying to find a needle in a haystack.” Today we might say, trying to find a book in your young teenager’s room.” It’s your choice as to phrasing a thought however this kind of sums up some of the diagnostic challenges that we face as NPs and PAs. There are spectrums of diseases that elude even the finest practitioner, some, like headaches, for the past five thousand years. Technological advances, radiological inventions, sophisticate genetic testing and elaborate blood tests, are still not capable of leading a clinician to an early and correct diagnosis.
“The patient with a headache often finds himself a medical orphan. He is fortunate indeed if he finds his headache transient, for otherwise he may find himself on an excursion to the ophthalmologist, otolaryngologist, neurologist, dentist, psychiatrist, chiropractor and the latest health spa. He is x-rayed, fitted with glasses, analyzed, massaged, relieved of his turbinate’s and teeth, and too often emerges with his headache intact.” Russell C. Packard in Headache, 1979 volume 19 page 370
Everyone reading this article has had a headache and for some, a chronic headache yet the word itself defies succinct definition. Volumes have been written about headaches yet the ultimate yield is still insufficient to relieve our patients and help the practioner whose responsibility is to magically make a proper diagnosis, treat the source of the problem and send the patient merrily on his way. This modality is one of the 10 most common reasons why a patient will visit their primary care provider and is among the most prominent causes of sick leave from employment. It is a problem that has a plethora of symptoms which seemingly outweigh the signs and remains as elusive as a needle in a haystack.
Headaches are considered as either primary or secondary. The primary headaches are those that effect 90% of the population and sit in your office each day while the secondary headaches are the cause of great morbidity and mortality and are the responsible entities of misdiagnosis that often leads to disablement and death. Don’t you think that it would be an asset to differentiate between the two? Treating patients with headaches require a specific approach which we call a “headache history.” This history is not unlike an abdominal pain history in that we seek to develop a story that becomes a vector to the proper diagnosis. This represents the detective work that is specific to this set of symptoms and defines a good clinician. Among the numerous questions that require a accurate response are the age of onset, the frequency and duration of the headache, the site of the pain, the quality of pain, the onset of pain, the aggravating factors and the positions or therapies that exacerbate the pain or relieve it. The difficulty of this history is in developing answers that are really reflective of the headaches in the past. The history becomes blurred by the failure of the patient to have a proper and correct recollection of each headache until their explanation becomes a blur of incidents that no longer represent the chief complaint with the exception of the main word, headache. How do we correct this problem? It is essential to have the patient develop a headache diary with at least three inferences to headaches since your primary exam that can accurately define the process and help you to formulate a differential diagnosis and a treatment plan. Examples of a good headache diary can be apprehended by contacting the American Headache society, the International Headache Society or the National Headache foundation.
The next portion of investigation relates to the proper physical examination. I have discovered that a clinician defines the problem or more accurately, approaches the problem from the tunnel vision of their own particular or specific area of specialty. A chiropractor will place the blame on cervical tension or neck related problems, the Opthmologist will “see” this as a problem related to eyestrain, the orthopedist to body mechanics, the cardiologist to hypertension, the psychiatrist to an emotion imbalance, the alternative medicine specialist to diet, relaxation and the need for treatment with Botox. It is no mystery why this phenomenon still exists and is rarely properly diagnosed. The physical exam is not unlike any other in that we need to ask ourselves if the patient looks sick, are they febrile, are they mentally alert, are there any positive neurological signs, are the cranial nerves intact, are the reflexes normal and in a general exam do they have ocular evidence of a major problem, do they have TMJ an earache, or any associated musculoskeletal problems.
The investigations that can be ordered are legion but why not start with the diary unless this patient is presenting with signs of a secondary headache which will require emergency sophisticated tests such as a CT scan, lumbar puncture, etc. The clinician needs to be aware of the potentially serious secondary headaches and their prognosis and modalities of treatment. Headaches represent an interesting problem that necessitate the clinician to have a certain amount of expertise and not offer two tablets and see me in the morning.
The Association of family Practice Physician Assistants will be having their annual Spring Conference in March and the author of this article will be speaking on the topic of “Finding the Needle in the Haystack.” This is an opportunity for clinicians to develop insights to good practice and gain information that will enable them to treat this portion of their practice. Is it the absolute answer to all of the questions related to this condition? No! The purpose of the lecture will be to distinguish between primary and secondary headaches and to help make the attendee confident and competent in their approach to diagnosis and treatment.
Contact the AFPPA for information concerning this CME offering and meet the author, Bob Blumm at their next conference in Orlando.
To register to see this presentation live follow this link: http://www.afppa.org/index.php?option=com_content&view=article&id=12&Itemid=15
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
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