Headache – A Telephone Encounter

Headache - A Telephone Encounter

Learning happens in between cases in the ER. Be it a well-managed case by your colleague or a particular procedure you could have done differently. You learn something after each encounter. At times, learning happens when most unanticipated. Like when you are about to snuggle into your warm bed after a tiring day at the ER. My night was supposed to be calm, maybe punctuated by some calls by a concerned parent of minor flu ridden child, but calm nevertheless. You would not have completed rehearsing your thank you message that you are going to say the day after to the scheduler and the telephone rings. You pick it up because that is literally the only job description for tonight. Answer health queries that people might have. No wonder I was brave enough to feel cozy on the bed in the telemedicine room. It was a call from a 37-year-old female who lived in a village almost 3 hours from Patan Hospital, where I was.

At Patan Hospital, a telephone-based telemedicine service is provided 24/7 via doctors and interns working in the ED. Telephone encounter with a patient has its own challenges. For one, you don’t get to see the patient and hence won’t be able to tell the degree of discomfort. All your Sherlock Holmes like sharp power of observation that you have built through years of practice can only use one of the multiple senses. Listening becomes not only the most crucial skill but the only available tool you have.

Fear to land in the wrong place

Sometimes, you hear that one word that triggers the fast-acting, decisive and flight or fight-mode-run emergency physician in you. That forces you out of habit to think parallel while taking history. A boon and a curse in its own might, differential diagnosis starts popping up and canceling themselves. The goal is either 1) providing the patient reassurance that nothing serious is going on and she can visit a primary care in convenience or 2) urging them to visit the nearest ER because something sinister might be going on. The division seems very black and white but the near distance between the two divisions is so big that you fear to land in the wrong place without a return ticket.

Differentiating headaches

For a starting practitioner that I was, differentiating primary headaches was easier in a precisely articulated MCQ but rather difficult in a real patient scenario.

Temporally jumbled case history, intersecting symptomatology, and vital clues to the diagnosis buried underneath a mist of unrelated information constitute a patient history. To dissect through that mist and reach a sensible differential is an art that comes with practice. As I am sure I will reiterate in years to follow, I hadn’t honed the art form to the degree I have now. I present to you a telephone conversation between an intern on duty at telemedicine and a patient with a headache.

Telephone encounter

Patient

Hello! I have a bad headache.

Me

Hi, I am sorry you have a headache. Let’s talk for a bit; I will try to quickly characterize your headache and advise you on what to do next. Does that sound like a good plan?

Patient

mm hmm. I haven’t had this bad headache ever.

‘First or worst headache’ - this sounds like SAH.

Me

On a scale of 1 to 10, how bad is it?

Patient

I would say 8!

Headache severity

Me

When did it start?

Patient

Around 2 hours ago.

Me

Have you had comparable headaches or headaches on a regular basis?

Patient

Sometimes. I don’t remember.

Me

Do you remember how your headache started? Have you hurt your head?

Trying to rule out the obvious causes like trauma.

Patient

No, I came back from work. At first, I felt nauseous. Then the head gradually started throbbing. It felt like a drum was beating in my head.

At that point, I decided to open up UptoDate and look through the causes of thunderclap headache. SAH, cerebral infections, HTN crisis, Ischemic stroke, cerebral venous thrombosis – the list continued. (1)

Me

Apart from nausea, do you have any other symptoms?

Patient

I am finding it difficult to stay in bright light.

Photophobia! Could this be meningitis or migraine?

Me

Do you feel feverish?

Patient

No

Me

Any rash?

Patient

None that I see.

CNS infection checked off. I feared that I was asking too many questions. Had she presented to the ER, I would have managed her pain first, ruled out my differentials with history taking and sent her for appropriate investigations. The inability to accurately assess the degree of pain further adds to the limits of telephone medicine – you have to trust what you hear without having the opportunity to manage in real-time. History is essential to a proper recommendation, especially when that is the only tool you have – I thought to myself.

Me

Do you have any trouble seeing or walking?

Patient

No

She has been answering well, so no difficulty in speech - her neurological status seems intact.

Me

Do you have any other medical problems? Are you under any medication?

Patient

No. I just took paracetamol but it was of no use.

Me

Do you have nasal congestion or discharge?

Patient

Not now, but I had the flu a week back.

Acute sinusitis is another common cause of headache. (2) Having ruled out serious threatening causes of headache. I was relieved – this sounded like a case of the primary cause of headache, a common presentation in every ER. I needed to remember the differences between different primary headaches – a quick UpToDate search away. Maybe, telemedicine does have some pros – like searching up the internet might not have been very appropriate while talking to your patient.

Me

Where is your pain? Does the pain seem to spread to any other area?

Patient

It’s just in front of my head.

Me

Did you feel anything abnormal before the headache started?

Trying to rule out any aura

Patient

No

Me

Do you feel the urge to isolate yourself and not hear loud noises.

Patient

No. Not really.

Me

From my evaluation, you seem to be having a tension headache. It is not a serious condition and is the most common cause of people presenting with headaches. (3) But I would suggest you visit your nearby health center to ensure you get the right diagnosis nonetheless.

Learning is the summation of moments

Learning is the summation of moments we really understand something, those aha moments, ones that feel like an epiphany. I always knew photophobia and phonophobia occur in migraine and not in tension headache. I may even have read before that day that one of those can happen in tension headache as well. But never had I ever imagined that one day I would reassure a patient that she has a tension headache because she doesn’t have both. The nature of medicine is such that we really learn something after each encounter.

References

  1. Schwedt TJ. Overview of thunderclap headache. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-thunderclap-headache
  2. Dodick D. Headache as a symptom of ominous disease. What are the warning signals?. Postgrad Med. 1997;101(5):46–50,55–6,62–4.
  3. Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache 2018; 58:339.

Further Reading

Cite this article as: Sajan Acharya, Nepal, "Headache – A Telephone Encounter," in International Emergency Medicine Education Project, January 20, 2020, https://iem-student.org/2020/01/20/headache-a-telephone-encounter/, date accessed: April 1, 2020

ICH

651.1 - ICH

Intracranial Hemorrhage chapter written by Nur-Ain Nadir and Matthew Smetana from USA is just uploaded to the Website!

Sudden Severe Headache

665-  SAH

In case you didn’t encounter a sudden severe headache today!

A 46-year-old female patient presented with severe headache. BP: 178/88 mmHg, HR: 103 bpm, RR: 22/min, T: 37, SpO2: 98% in room air. She has no history of disease. She is unconscious (GCS E1, V3, M4). No obvious lateralized motor deficit. Bedside gluco-check is normal. You intubated her to secure airway and send her to the CT (above image). What is your next action?

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Head CT Interpretation – No Worries!

Give Me A Headache!

Headache

by Matevz Privsek and Gregor Prosen, Slovenia

A 52-year old male comes to the ED with a severe headache. A triage nurse gives you his chart and says that his vital signs are normal, but he does not look well. You start to question the patient, and the following history is obtained: his headache started approximately six hours ago. He was working in his office when he started to feel squeezing-like sensation in his head. The pain has gotten worse since then, but it is still tolerable. It is independent of any physical activity or position. He already had a few similar episodes of this kind of headache in the past two years, but now the pain does not go away after aspirin as it did previously. He denies trauma as well as any associated symptoms, e.g. no visual disturbances, hearing loss, weakness, dizziness, stiff neck, loss of consciousness. He is otherwise a healthy, non-smoker, with no regular therapy or known allergies. His clinical exam is unremarkable. Conscious, GCS 15, alert and oriented, normal skin color. Blood pressure 135/82 mm Hg, pulse 78/min, 14 breaths/min, SpO2 99%, body temperature 36,4 °C. Neurologic exam shows no declines from normal, as well as the rest of the physical exam.

 

slovenia
Matev Privsek, Slovenia
Gregor Prosen, Slovenia

How many headache patients you may encounter today?

Touch Me

3-5% of all ED patients

So, theoretically, if your ED sees 300 patients a day. You have a chance to see 9-15 patients in 24 hours. Not bad! 3-5 in an 8 hours shift.
Answer

What is your diagnosis ?

You set up an intravenous cannula, draw blood for testing, and gave the patient some parenteral analgesics (metamizole 2.5 g, ketoprofen 100 mg) along with 500 ml of normal saline. You put him into the observation room. Lab results (complete blood count, basic biochemistry panel) came back in 2 hours and are completely normal. The patient now feels much better, with almost no headache at all. Repeated vital signs and clinical exam are again unremarkable. You explain to the patient that most likely he had a tension headache, warn him about red flags regarding headaches, and discharge him home with a prescription for peroral analgesics with a follow-up at his general physician.