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Chapter 19 • Headache
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229
the knee joint when the hip joint is exed may cause
the other limb to ex at the hip (Kernig sign).
Assess Motor Strength and Coordination
of Extremities
Asymmetrical increase in muscle tone on the affected
side, contralateral to the hemisphere lesion, suggests a
cerebral lesion.
Patients who exhibit forearm drift with arms extended and eyes closed may have a motor neuron or
cerebellar disturbance with an expanding intracranial
lesion.
Test Balance and Gait
Midline cerebellar abnormalities cause marked ataxia.
The patient has difculty standing on the ipsilateral
leg and has a tendency to fall or stumble toward the
side of the lesion. The gait is also wide-based and
halting, and the patient turns with jerky movements.
Minimal disturbance is observed when the patient
hops on either foot or stands tandem (one foot behind
the other).
Assess Deep Tendon Reflexes
Note asymmetry, absence of reexes, or hyperactive
responses. Increase in, or asymmetry of, reexes is seen
with cerebral lesions. The plantar or Babinski response
is often present with cerebral lesions.
Have Children Draw Pictures of their Headaches
Having a child draw a headache is an inexpensive and
accurate way to help diagnosis headaches. The child
is given a plain piece of paper and asked to draw a
picture of how his or her headache felt before any
history of the headache is taken. These drawings help
to diagnose migraine headaches. Drawings for migraines include visual images such as ashing. Showing the lights being turned off, a dark room, or a
blanket over the head depicts photophobia. The need
to lie down is also associated with migraine headache. Images for nonmigraine headaches show pictures of pounding or tight headbands. Even very
young children (age 4) are able to draw stick gures
with signicant detail.
LABORATORY AND DIAGNOSTIC STUDIES
Complete Blood Count
Complete blood count (CBC) with differential is obtained to detect major blood dyscrasias. Hypoxia secondary to severe anemia can cause headache. In bacterial
meningitis the polymorphonuclear leukocytes (PMNs)
will be high with a left shift.
Blood Cultures
Blood cultures should be drawn in a patient who has a
fever, headache, nuchal rigidity, and altered mental
status.
Computed Tomography Scan
CT scanning is the most common noninvasive initial
diagnostic tool used to detect intracranial disease
and should be done with new-onset severe headache
or headache associated with abnormal neurological
signs. CT scanning has essentially made angiography,
ventriculography, and radionuclide brain scanning
obsolete.
Magnetic Resonance Imaging
An MRI image changes over time as red cells lyse and
hemoglobin degrades. It is the rst imaging choice for
a brain abscess.
Lumbar Puncture
Lumbar puncture (LP) can measure cerebrospinal
uid pressure directly and can be analyzed for normal values of components that are altered by disease
such as lymphocytes, glucose, protein, and presence
of bacteria. An LP is performed when a central nervous system infection is suspected but is contraindicated if there is suspicion of increased intracranial
pressure.
Erythrocyte Sedimentation Rate
Erythrocyte sedimentation rate (ESR) is a nonspecic
test that is elevated in the presence of inammation. An
ESR should be performed when temporal arteritis is
suspected.
Skull Radiograph
A radiograph of the skull is useful in posttraumatic
headache. Specic views must be obtained to better
observe intracranial structures such as the pituitary
gland or paranasal sinuses.
DIFFERENTIAL DIAGNOSIS
Primary Headaches
Tension-Type Headache (Muscle)
TTH is the most common type of headache in adults
and occurs most often in women. The exact mechanism of tension headache is uncertain but is related to
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Chapter 19 • Headache
sustained muscle contraction. Tension headache produces a bilateral pain, general or localized, often described as a frontotemporal band-like distribution. The
discomfort is described as a mild to moderate, nonthrobbing pain, tightness, or pressure with a gradual
onset. It may last for hours or days and recurrences
may extend over weeks or months. It is associated with
hunger, depression, or stress.
Migraine Without Aura (Common)
About 20% of adults experience migraines, and episodes are not uncommon in children as young as
5 years old. The headache is unilateral and throbbing
and most often accompanied by nausea, photophobia,
and exacerbation from physical activity. The headache is usually frontal or periorbital. Onset is rapid,
and crescendo is within hours. Migraines may recur
daily, weekly, or less often. Migraine headaches are
most commonly found in adults 25 to 34 years of age
and are rare during pregnancy. Chronic migraine is
present when attacks occur more than 15 days in
a month.
Migraine With Aura (Classic)
Neurological signs that indicate cortical and/or brainstem
involvement precede classic migraine headaches. Bright
lights, noise, or tension may precipitate headaches. Auras
may include visual disturbances (e.g., scintillating scotoma: a pattern of twinkling colored lights), ascending
paresthesias or numbness, weakness, and aphasia. The
pain may be associated with photophobia, phonophobia
(noise sensitivity), nausea, and vomiting. Aura usually
precedes but may accompany a headache or occur without headache.
Mixed Headache
Mixed headaches are a combination of muscular contraction and vascular dysfunction. The headache is
experienced as a throbbing, constant pain during waking hours with symptoms of tightness, pressure, and
muscle contraction. Family history of migraine is not
uncommon.
Cluster Headache
Cluster headaches are of vascular origin and are less
common than migraines. The onset is abrupt, often
during the night, and the severity increases steadily.
The pain is unilateral, ocular, or periocular, and described as burning, piercing, or neuralgic. Cluster
headaches occur more often in men and last 15 minutes
to 2 hours. The episodic recurrences are “clustered” in
cycles of days or weeks with remission lasting months
to years. Associated symptoms include ipsilateral rhinorrhea, conjunctival injections, facial sweating, ptosis, and
eyelid edema. Alcohol ingestion, stress, or vasodilation
secondary to wind or heat exposure may precipitate
the pain.
Benign Exertional Headache
These headaches occur suddenly and are related
to coughing, sneezing, straining, running, or orgasm.
Headache is the result of stretching the pain-sensitive
structures in the posterior fossa. They are more common in men. The onset is sudden and “splitting,” and
pain may last from seconds up to 30 minutes. They
should be distinguished from headache of SAH or
arterial dissection.
Secondary Headaches
Infectious Origin
Sinusitis. Sinusitis is frequently associated with a sore
throat irritated by postnasal discharge, facial or tooth
pain, or a headache over the affected sinus that increases in intensity with coughing or bending forward.
There frequently is a cough that worsens in a lying
position, morning periorbital swelling, fever, malaise,
and recent upper respiratory tract infection. The maxillary sinuses are the most often affected. Pain in the
temporal and periorbital area suggests frontal sinusitis,
whereas maxillary sinusitis produces pain below the
eye, in the upper teeth, or both. Ethmoid sinusitis produces medial orbit pain.
Dental disorders. Patients with dental abscess,
nerve root dysfunction, or infection may have headache and facial pain located near the site of the lesion.
Tenderness elicited by tapping on the maxillary teeth
with a tongue blade may indicate dental root infection
or maxillary sinusitis. Inspection of the mouth may
reveal ulceration or infection of pain-sensitive structures in the oral mucosa and gingiva.
Pharyngitis. Bacterial infection may irritate pain-
sensitive structures in the oropharynx, leading to
headache.
Otitis media. Recurrent otitis media with sequelae
of mastoiditis or chronic infection may result in headache. Signs of otitis will be seen on examination of the
tympanic membrane.
Meningitis. Bacterial meningitis begins as bacteria
colonize in the nasopharynx and enter the central nervous system through the dural venous sinuses or choroid plexus into the subarachnoid space. Common causal
organisms in adults are Staphylococcus pneumoniae
Chapter 19 • Headache
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231
and meningitidis. In children, common organisms are
S. pneumoniae and Haemophilus inuenzae; in neo-
nates, group B Streptococcus and Escherichia coli.
Bacterial meningitis is usually accompanied by severe
systemic toxicity and mental status changes (encephalitis). In contrast, aseptic meningitis caused by enteroviruses or mumps virus produces a mild illness sometimes without fever. Photophobia and stiff neck are
present in varying degrees. The person usually appears
ill with a severe headache, fever, chills, myalgias, photophobia, and stiff neck. The Brudzinski and Kernig
signs may be positive. A petechial skin rash may suggest meningeal disease. Patients may progress to coma
and have seizures.
Neurogenic Origin
Trigeminal neuralgia. The pain associated with mal-
function of the trigeminal nerve (cranial nerve V) is
characterized by episodes of a series of bursts or jabs
of sharp electrical, stabbing pain lasting seconds that
occur repeatedly over minutes or hours with a minute
or so of relief between episodes. The pain is limited
to the distribution of the three branches of cranial
nerve V. Headaches caused by trigeminal neuralgia are
stimulated by sensory stimuli to the involved nerves,
produced by rubbing or touching the face or swallowing. Trigeminal neuralgia usually occurs in women
and individuals older than age 55. In younger patients,
episodes may indicate multiple sclerosis.
Optic neuritis. Optic neuritis refers to a variety
of conditions that affect the optic nerve and reduce
visual function. Disorders include demyelinating disease (such as multiple sclerosis), inammation, viral
illness, metabolic disorders, and toxin exposure. The
patient has an acute onset of blurred vision with extraocular motion pain that precedes the visual changes
by several days. Ophthalmoscopic examination reveals a slightly elevated (hyperemic) disc and a
blurred disc margin. Treatment is focused on the underlying disease.
Cervical spine disorders. The three upper cervical
nerves are sensory pathways for pain sensation felt in
the posterior head and ipsilateral temporal and eye
areas (see Figure 19-2). Disturbances in the neck may
cause muscle spasms and pressure on other neck structures. Patients with neck-related headache have pain
associated with motion of the neck. Downward pressure on the head makes the pain worse and may cause
it to travel down the arms.
Temporal arteritis (giant cell arteritis). Temporal
arteritis is a vasculitis of the ophthalmic and posterior
ciliary branches of the internal carotid artery. It almost
always affects people older than age 50. It produces a
sharp, localized pain over a tender, nodular temporal
artery. Other symptoms include fever, malaise, anorexia,
weight loss, and/or polymyalgia rheumatica. Ischemic
jaw pain and face pain are rare but highly suggestive.
Headaches precede the major danger of temporal arteritis (blindness) by weeks. Unilateral blindness may
occur suddenly and is not reversible. Left untreated,
blindness may occur in the other eye. An ESR greater
than 50 mm/hr is almost always present. Suspected
temporal arteritis is an emergency, and the patient needs
referral to an emergency center for immediate evaluation and treatment.
Metabolic Origin
Carbon monoxide poisoning. CO is a colorless,
odorless gas with an afnity for binding with hemoglobin to produce carboxyhemoglobin (COHb), which
impairs oxygen transport. Symptoms are nonspecic
and are dose related. Low COHb levels may produce
mild dyspnea and tightness across the head; however,
as COHb concentration increases, the headache becomes more severe and is associated with dizziness,
nausea, fatigue, and dimmed vision. As COHb levels
rise, symptoms increase in severity and lead to loss of
consciousness, and seizures. Blood gases and COHb
blood levels are diagnostic. History may suggest recent smoke inhalation or similar symptoms in multiple
family members.
Severe hypoglycemia. Hypoglycemia is more
likely to occur in individuals with type 1 diabetes, but
can occur in anyone taking oral hypoglycemic agents,
in younger people who experience reactive hypoglycemia, or in people who have ingested excessive amounts
of alcohol. A dietary and medication history may lead
to a specic causative factor. Headache is generalized
and bilateral and is associated with dizziness and a
sense of not feeling well. Some people with diabetes
may have nocturnal hypoglycemia and report nightmares and vivid dreams, night sweats, and a headache
on awakening. Blood glucose levels can conrm the
presence of hypoglycemia.
Drug withdrawal. Withdrawal from prolonged
use of steroids may cause migraine headaches. Nitrites
may precipitate headache. Other drugs causing cranial
dilation and an after effect of rebound vasoconstriction
include hydralazine, alcohol, histamine, nicotinic acid,
and caffeine.
Dietary ingestion. A mild to moderately severe
generalized headache may occur after ingestion of
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Chapter 19 • Headache
tyramines (e.g., aged cheese, red wine), monosodium
glutamate, and nitrites in smoked meats. A headache
diary will help identify the pattern of headache related
to specic foods.
Cerebrovascular Origin
Intracranial tumor. Primary intracranial tumors are
more common in children than adults. Brain metastases from primary sites in the lung, breast, or kidney are
more common in adults. Pain is constant and progressive, is felt in a discrete location, changes with head
position, and awakens the person from sleep. Objective
neurological signs are present in 98% of all children
with brain tumors.
Hydrocephalus. Hydrocephalus is an excessive col-
lection of cerebrospinal uid (CSF) in the ventricles of
the brain and can be caused by tumors or cysts. If fontanels are still open, hydrocephalus will cause an enlargement of the head on measurement. Headache will be
progressive and may be associated with neurological
ndings and mental status changes similar to those
observed with dementia. Radiographic techniques are
diagnostic, and LP may detect increased CSF pressure.
Subdural hematoma. Acute subdural hematoma
(SDH) produces a sudden, severe headache and may be
associated with a history of head trauma, exertional
physical activity, or pharmacological anticoagulation.
There is transient loss of consciousness, stiff neck,
nausea, vomiting, photophobia, pupillary dilation, and
pain over the eye. It is essential to obtain a thorough
history of trauma. Post-trauma headache can occur
hours or a day after injury.
Pseudotumor cerebri. Teenagers being treated
with topical acne preparations, menopausal women,
and individuals ingesting large amounts of vitamin A
are at increased risk for pain from pseudotumor cerebri. Papilledema will be present in many cases, but
without it, the headache may be diagnosed as mixed
type. A neurology referral is indicated to ensure that no
local obstruction is present before an LP is done to
assess for increased intracranial pressure. An LP sometimes leads to herniation of the brainstem.
Brain abscess. Onset of pain can be gradual or
severe, deep, and aching in nature, often worse in
morning and aggravated by coughing or straining.
Pain is usually localized to the side of the abscess.
Other signs of increased intracranial pressure may
be present, such as papilledema and widening pulse
pressure. There may be a recent history of head injury,
infections (e.g., dental abscess, otitis media, or sinusitis), or assault to the central nervous system.
Intracerebral hemorrhage. Intracerebral hem-
orrhage (ICH) may result in a stroke or sudden coma
and is associated with neurological ndings dened
by the site of bleeding. A person may present with a
sudden-onset, severe headache, with or without a
history of trauma. The severity of symptoms from
bleeding intracranial aneurysms is correlated to the
rate of hemorrhage and graded from I (asymptomatic
to minimal headache with nuchal rigidity) to V
(deep coma, decerebrate rigidity). Geriatric patients
with AIDS and patients prescribed anticoagulation
therapy are at increased risk for ICH. CT scan is
diagnostic.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
PRIMARY HEADACHES WITHOUT STRUCTURAL OR SYSTEMIC PATHOLOGY
Tension-type
headache (muscle)
Migraine without aura
(common)
Migraine with aura
(classic)
Mixed headache Throbbing, constant pain during
Common Causes of Headache
Common in adults; bilateral pain,
general or localized in bandlike
distribution; history of anxiety,
stress, or depression
More common in children; unilat-
eral, throbbing pain; nausea
Pain precipitated by environmental
stimuli; visual disturbances
(scintillating scotoma) precede
pain
waking hours; muscle tightness;
family history of migraine
Normal physical examination;
neck muscle tightness or
fasciculations may be
palpated
Photophobia and phonophobia None
Nausea and vomiting, photo-
phobia and phonophobia
Mix of findings related to ten-
sion and migraine headache
pain
None
None
None
Chapter 19 • Headache
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233
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Headache — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Cluster headache Rare in children; abrupt, nighttime
onset; unilateral periorbital pain
Benign exertional
headache
SECONDARY HEADACHES WITH STRUCTURAL OR SYSTEMIC PATHOLOGY
Infectious Origin
Sinusitis
Dental disorders Localized pain in jaw and top of
Pharyngitis Sore throat Fever; infection of posterior
Otitis media Ear pain, pain with swallowing Fever; red, bulging tympanic
Meningitis
that is severe
Sudden onset related to physical
exertion, Valsalva maneuver, or
coitus
Frontal, upper molar, or periorbital
pain; cough, rhinorrhea
head
Severe headache, chills, myalgias,
stiff neck; toxic child or adult
Ipsilateral rhinorrhea, nasal
stuffiness, conjunctival
injection, sweating, ptosis
Normal physical examination May need to distinguish
Low to no fever; pain on palpa-
tion of frontal, maxillary
sinuses; purulent nasal or
postnasal discharge
Malocclusion, caries, ab-
scesses of teeth present,
gum disease
pharynx
membrane
Positive Kernig and Brudzinski
signs; fever, photophobia,
petechial rash may be present; mental status changes
None
from subarachnoid
hemorrhage with
CT scan
Radiographs
(Waters view)
Dental referral
Throat culture
None
Lumbar puncture
Neurogenic Origin
Trigeminal neuralgia
Optic neuritis Acute onset of pain with extraocu-
Cervical spine
disorders
Temporal arteritis
Metabolic Origin
Carbon monoxide
poisoning
Severe hypoglycemia History of diabetes or medication,
Drug withdrawal Pattern of headache associated
People .55 yr; bursts of sharp
pain over face innervated by
affected nerve; triggered by
stimulus to affected nerve
lar movement (EOM), followed
by blurred vision
May have history of trauma;
occipital pain, muscle stiffness
Age .50 yr; sharp, localized
temporal pain; malaise, anorexia; history of polymyalgia
rheumatica
History of exposure; throbbing
headache, mild dyspnea
alcohol, and food ingestion; generalized headache, dizziness,
sense of not feeling well
with stopping medication or
substance use
Normal physical examination;
stimulation of triggers may
provoke pain
Diminished visual acuity,
decreased papillary reflex,
hyperemia of optic disc;
pain with EOM
Normal physical examination
or pain associated with neck
motion
Fever, weight loss; tender over
a nodular temporal artery
Nausea, vomiting, change in
mental status, lethargy, loss
of consciousness
Normal physical examination
or pallor, sweating, and
weakness
Normal physical examination Blood chemistry
None
Ophthalmology referral
Cervical spine
radiographs
Elevated ESR (.50);
immediate referral
for treatment
Blood gases and
carboxyhemoglobin
level
Blood glucose level; may
need self-monitoring
of blood glucose to
establish pattern
Continued
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Chapter 19 • Headache
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Headache — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Dietary ingestion Mild to moderately severe head-
ache after ingestion of foods
or medication
Cerebrovascular Origin
Intracranial tumor Sudden-onset headache that is
Hydrocephalus Progressive headache, vomiting,
Subdural hematoma History of head trauma, bleeding
Pseudotumor cerebri Teens, menopausal women; history
Brain abscess History of chronic ear infection or
Intracerebral
hemorrhage
AIDS, Acquired immune deficiency syndrome; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging.
progressive, exacerbated by
coughing or exercise; worse in
morning; history of trauma
increases risk
irritability
disorders, child abuse; adult
.35 yr; sudden onset of “worst
headache ever,” often over eye;
transient loss of consciousness
of vitamin A or tetracycline ingestion; progressive headache
cyanotic heart disease
Risk factors: people .50 yr, with
AIDS, taking anticoagulation
therapy, hypertension
Normal physical examination Blood chemistry
Papilledema, vomiting, asym-
metrical reflexes, weakness,
sensory deficit, or other
neurological deficit
Rapid enlargement of head,
bulging fontanels
Unequal pupils, photophobia,
neurological changes,
seizure
Papilledema may be present CT scan, neurology
Fever, seizures, focal neurolog-
ical deficits
If conscious, abnormal neuro-
logical findings correlated
with extent of lesion
CT scan
CT scan and referral
CT scan and neurosur-
gical referral
referral to assess risk
related to lumbar
puncture
MRI
Emergency transport for
immediate evaluation
(CT, MRI and possible
surgical treatment)
References and Readings
American College of Emergency Physicians: Clinical policy: Criti-
cal issues in the evaluation and management of patients presenting to the emergency department with acute headache, Ann Emerg
Med 52:407, 2008.
Blume H: Pediatric headache a review, Pediatr Rev 33:562, 2012.
Davenport R: Headache, Pract Neurol 8:335, 2008.
Dodick DW: Pearls: Headache, Semin Neurol 30:74, 2010.
Hampson N, Piantadosi C, Thom S, Weaver L: Practice recommen-
dations in the diagnosis, management, and prevention of carbon
monoxide poisoning, Am J Respir Crit Care Med 186:1095, 2012.
Kabbouche M, Cleves C: Evaluation and management of children
and adolescents presenting in an acute setting, Semin Pediatr
Neurol 17:105, 2010.
Kaniecki R: Headache assessment and management, JAMA 289:
1430, 2003.
Lewis DW: Pediatric migraine, Pediatr Rev 28:43, 2007.
Lipton RB, Bigal ME, Steiner TJ, et al: Classication of primary
headaches, Neurology 63:427, 2004.
Manzoni GC, Torelli P: Headache screening and diagnosis, Neurol
Sci 25:S255, 2004.
Moragas-Garrido M, Davenport R: Acute headache, Medicine 41:
164, 2013.
Purdy RA: Clinical evaluation of a patient presenting with headache,
Med Clin North Am 85:847, 2001.
Reeves AG, Swenson RS: Disorders of the nervous system: A primer,
Dartmouth Medical School, 2008. Retrieved from http://www.
dartmouth.edu/,dons/index.html.
Roser T, Bonfert M, Ebinger F, et al: Primary versus secondary head-
ache in children: A frequent diagnostic challenge in clinical routine,
Neuropediatics 44:34, 2013.
Smetana GW: The diagnostic value of historical features in primary
headache syndromes, Arch Intern Med 160:2729, 2000.
Stafstrom CE, Rostasy K, Minster A: The usefulness of children’s
drawings in the diagnosis of headache, Pediatrics 109:460, 2002.
CHAPTER
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20
eartburn is a sensation of burning, warmth, or
H
heat in the retrosternal area between the xiphoid and manubrium. In contrast, indigestion refers to pain or discomfort in the upper abdomen
without radiation that occurs with eating or soon
after a meal.
Patients describe heartburn using a variety of terms
including indigestion, acid regurgitation, sour stomach, and bitter belching. The burning sensation often
begins inferiorly and radiates up the entire retrosternal
area to the neck, occasionally to the back, and rarely
into the arms. Heartburn can be a result of gastroesophageal acid reux that occurs as a consequence of
lower esophageal sphincter relaxation. Acid reux may
or may not cause tissue damage and erosions. In erosive reux disease (erosive esophagitis or Barrett
esophagus), mucosal breakdown allows reuxed acid
to irritate local nociceptors. Not all reux results in
heartburn, and not all heartburn is caused by reux.
For example, heartburn can be a symptom of angina
or myocardial infarction (MI). Heartburn is different
from localized gastric or epigastric burning, which
most likely represents dyspepsia.
Indigestion is commonly triggered by overeating;
eating too fast; stress; excess alcohol; caffeine intake;
and fatty, greasy, or spicy foods. Patients may report
associated symptoms of postprandial fullness, upper
abdominal bloating, early satiation, epigastric burning, belching, nausea, and vomiting. Indigestion that
is chronic or recurrent is typically associated with
dyspepsia. Indigestion is usually not a symptom of a
serious health problem unless it occurs with other
symptoms such as chest pain and shortness of breath
that suggest a cardiac origin; painful or difcult swallowing, unintentional weight loss, persistent vomiting,
or gastrointestinal (GI) bleeding that suggest serious
upper GI conditions. Although heartburn and indigestion can be symptoms of distinct entities, there is
considerable symptom overlap, and one or both symptoms can occur in conditions such as gastroesophageal
Heartburn and Indigestion
reux disease (GERD), peptic ulcer disease, gastritis,
and gastric cancer.
The immediate concern when patients present with
heartburn or indigestion is to assess for alarm symptoms that require immediate endoscopy.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is immediate endoscopy necessary?
Key Questions
l
Do you have trouble swallowing? If yes, is it solids
or liquids?
l
Do you have pain with swallowing?
l
Have you had unintentional weight loss?
l
Do you have persistent vomiting?
l
Have you had rectal bleeding, blood in your stool, or
told that you have anemia?
Alarm Symptoms
The symptoms of most concern are dysphagia, odynophagia, unintentional weight loss, persistent vomiting, GI bleeding, and unexplained anemia. These
are alarm symptoms for a serious condition and require immediate evaluation. These symptoms suggest either the presence of upper GI cancer, peptic
ulcer disease, or the development of a GERD-related
complication. Dysphagia suggests erosive or Barrett
esophagus, or gastric or esophageal cancer. Pain with
swallowing suggests esophageal ulcer. Unintentional
weight loss in the presence of dysphagia or odynophagia is suggestive of cancer. GI bleeding and
anemia are suggestive of cancer or ulcer disease.
Unexplained iron deciency anemia indicates esophageal ulcer.
Mechanical obstruction of solid foods is suggestive of peptic stricture. Liquid obstruction suggests
a neuromuscular disorder, neoplasm, or esophageal
diverticulum.
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Could this be cardiac in origin?
Chapter 20 • Heartburn and Indigestion
Key Questions
l
Are the symptoms provoked by exertion or activity?
l
Are the symptoms relieved by rest?
l
Does the sensation radiate to the left shoulder, down
the arm, or to the neck or jaw?
l
Is there shortness of breath, nausea, vomiting, or dia-
phoresis?
l
How long do the symptoms last?
l
Does the patient have risk factors for cardiac dis-
ease? (older age, smoker, hyperlipidemia, hypertension, diabetes, obesity, history of coronary artery
disease [CAD], family history of CAD)
Symptom Characteristics
Heartburn and indigestion can be symptoms of angina
or MI. Pain arising from the GI and cardiac systems
transmits to the same spinal cord segments, T1 through
T5, and makes identication of the specic origin of
discomfort difcult. Therefore it is essential to determine if the symptoms are cardiac or gastrointestinal
in origin. The typical onset of angina occurs during
exercise or exertion. Symptoms typically last 2 to
10 minutes and are relieved by rest or nitroglycerin.
Symptoms from acute coronary insufciency last no
longer than 30 minutes. Anginal pain typically radiates
to the left shoulder and down the left arm and can
extend to the neck and lower jaw. Heartburn from noncardiac conditions rarely radiates down the arms.
Myocardial infarction can occur at any time and is
not relived by rest or nitroglycerin. Onset is acute. Pain
can radiate to the throat or neck, across both sides
of the chest to the shoulder, and/or down the medial
aspects of either or both arms. The chest symptoms
are often associated with shortness of breath, nausea,
vomiting, and diaphoresis.
See Chapter 8 for additional assessment of chest
pain.
Cardiac Risk Factors
A quick review of risk factors for cardiac disease helps
provide context for the presenting symptom(s).
What symptom characteristics will help me narrow
the differential?
l
What relieves the heartburn?
l
Do you have nighttime symptoms?
l
Do you have hoarseness, wheezing, or cough?
Description of the Sensation
Heartburn that is burning and stinging is a classic
symptom of GERD. The burning sensation or unpleasant subjective sensation of heat often begins inferiorly
and radiates up the entire retrosternal area to the neck,
occasionally to the back, and rarely into the arms.
Burning epigastric pain is a symptom of dyspepsia
and is not considered to be heartburn unless the pain
radiates retrosternally.
Patients with dyspepsia (both ulcer and functional) report epigastric pain or burning. Epigastric
pain is located in the region between the umbilicus
and lower end of the sternum, within the midclavicular lines. Epigastric pain may or may not have a
burning quality.
Regurgitation
The regurgitation of gastric contents into the mouth
(water brash or pyrosis) is a cardinal symptom of
GERD. Infants 6 months of age or younger often
have the return of small amounts of swallowed food
or liquid shortly after feeding. This is referred to as
spitting up.
Postprandial Fullness, Early Satiation
Dyspepsia commonly presents with postprandial
fullness or early satiation. Postprandial fullness is
described as an unpleasant sensation of prolonged
persistence of food in the stomach. Early satiation is
the loss of appetite during a meal and is described as a
feeling that the stomach is full soon after starting to eat
so that the meal cannot be nished.
Aggravating or Precipitating Factors
Symptoms from reux occur postprandially, particularly after large meals, or after ingesting spicy foods,
citrus products, fats, chocolates, and alcohol.
The supine position and bending over may exacerbate heartburn from GERD. Symptoms from hiatal
hernia may worsen on reclining. In gas entrapment,
pain is intensied by bending over or wearing tight
garments.
Key Questions
l
Describe the sensation.
l
Do you regurgitate gastric contents into the mouth?
l
Do you have postprandial fullness or early satiation?
l
What are the aggravating or precipitating factors?
Relieving Factors
Heartburn caused by GERD may be relieved by the
ingestion of antacids, baking soda, or milk. Heartburn
that is relieved by reducing the meal size, avoiding
high-fat meals, and eating slowly suggests GERD.
Chapter 20 • Heartburn and Indigestion
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237
EVIDENCE-BASED PRACTICE
Can GERD Be
Diagnosed by Symptoms Alone?
The symptoms of heartburn and regurgitation are used for
making a presumptive diagnosis of GERD. Included in a
larger systematic review, was a review of seven studies to
assess the accuracy of clinical opinion in diagnosing
esophagitis. A total of 5134 patients were included;
894 (17%) had esophagitis on endoscopy. The sensitivities
of heartburn and regurgitation for determining the presence
of erosive esophagitis were 30% to 76%, with specificities
ranging from 62% to 96%. The authors concluded that
symptoms alone do not have high diagnostic accuracy.
However, the clinical history is important in distinguishing
upper GI disorders from other disorders such as angina.
Reference: Moayyedi P, Talley NJ, Fennerty MB, Vakil N: Can the clinical
history distinguish between organic and functional dyspepsia? JAMA
295:1566, 2006.
Ingesting food may relieve symptoms from ulcer
disease. Symptoms from gas or gas entrapment are
relieved by passage of atus.
Nocturnal Symptoms
Many patients with GERD report nocturnal symptoms
that interrupt sleep and health-related quality of life.
Patients with peptic ulcer disease also report nocturnal
symptoms.
and those with a family history of gastric cancer. The
prevalence of erosive esophagitis and Barrett esophagus increases with age.
What else do I need to consider?
Key Questions
Is the patient a child?
l
Have you had recent GI surgery?
l
What medications are you taking?
l
How much alcohol do you drink?
Child
In infants, gastroesophageal reux (GER) is the most
common esophageal disorder. Symptoms often peak at
4 months of age and resolve by 12 to 24 months. Infants
with GER may present with postprandial regurgitation,
irritability, arching, choking, gagging, feeding aversion,
failure to thrive, obstructive apnea, or stridor. Cow’s milk
protein is a common cause of gastroesophageal reux in
infants, and a trial of elimination should be considered.
Older children with GER experience abdominal pain,
chest pain, asthma, hoarseness, and sinusitis.
Allergic eosinophilic esophagitis (AEE) occurs
primarily in young children and adolescents and presents with dyspepsia symptoms of reux or vomiting,
irritability, food refusal, and early satiation.
Extraesophageal Symptoms
Additional symptoms of hoarseness, wheezing, and
cough support a diagnosis of GERD. The causal relationship between asthma and GERD is difcult to
establish because either condition can aggravate the
other. Asthma can cause increased reux by creating
negative intrathoracic pressure and overcoming the
lower esophageal sphincter barrier.
Is this patient at risk for a serious underlying
condition?
Key Questions
l
If the patient is over 45 years old, is this a new onset
symptom?
l
How long have you been having symptoms?
l
Do you have a family history of gastric cancer or
peptic ulcer disease?
At-Risk Patients
Patients at high risk for a serious underlying condition
such as esophageal or gastric cancer or peptic ulcer
disease include patients older than 45 with new onset
of symptoms, patients with longstanding symptoms,
Recent GI Surgery
Reux of bile can occur after partial gastrectomy, truncal vagotomy and pyloroplasty for peptic ulcer reux
or cholecystectomy. Bile reux can cause severe
epigastric abdominal pain accompanied by bilious
vomiting and weight loss.
Medications
The ingestion of aspirin, nonsteroidal antiinammatory drugs (NSAIDs), or corticosteroids can cause
mucosal irritation of the esophagus and stomach. This
acute injury is produced by contact with a damaging
agent. Other medications that cause esophagitis or gastritis include tetracycline, potassium chloride, ferrous
sulfate, and alendronate.
Medications that may decrease lower esophageal
sphincter pressure and are associated with GERD include calcium channel blockers, alpha adrenergic antagonists, anticholinergic drugs, theophylline, nitrates,
sildenal, albuterol sedatives, and prostaglandins.
Alcohol
Chronic or excessive alcohol intake is associated with
GERD, esophagitis, gastritis, and dyspepsia.
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Chapter 20 • Heartburn and Indigestion
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Note General Appearance
Physical examination often has no specic ndings.
Look for pallor, diaphoresis, distress, and anxiety that
would suggest MI. Pallor may also suggest anemia
or allergic disorder as a cause of the symptoms.
Cachexia points to advanced cancer or compromised
nutrition.
Assess Vital Signs
Vital signs will generally be within normal range.
Variation in pulse, blood pressure, or presence of fever
should alert you to infection or a serious underlying
condition.
Assess Weight
Compare previously recorded weights. Unintentional,
unexplained weight loss suggests the presence of
cancer (see Chapter 39). Weight loss in the adult is
clinically signicant when it exceeds 5% of usual
body weight over a 6 to 12 month period. In infants a
decrease in weight of more than 8% necessitates
follow up within 48 hours. A loss of more than 10%
of birth weight warrants careful assessment and consideration for hospital admission.
Obesity is associated with the development of
GERD, esophagitis, hiatal hernia, and upper GI cancers. Obesity results in an increase in intragastric pressure, which increases the gastroesophageal pressure
gradient and the frequency of transient lower esophageal sphincter relaxation, thereby predisposing gastric
contents to migrate into the esophagus. In addition,
obesity enhances the spatial separation of the crural
diaphragm and the lower esophageal sphincter, thereby
predisposing to a hiatal hernia.
Examine the Skin
Evidence of atopic dermatitis suggests AEE and may
include acute and chronic eczematous lesions. Acute
lesions may be erythematous papules that are inamed
or crusty and oozing if they have been scratched.
Chronic lesions may be discolored, thickened, or scaly.
The symptoms of atopic dermatitis vary with the age of
the patient. In infants, the condition usually causes red,
scaly, oozy, and crusty cheeks, and the symptoms may
also appear on the neck and extensor surfaces of the
legs and arms. Adolescents are more likely to develop
thick, leathery, and dull-looking lesions on the face,
neck, and in the exural folds of the extremities.
Auscultate the Lungs and Percuss the Chest
Absent breath sounds, the ability to hear peristalsis in
the chest, or dullness of the left lung base, suggests a
large hiatal hernia. Wheezing may be present if the
patient has asthma.
Auscultate Heart Sounds
Abnormal sounds, such as paradoxical second heart
sound (S2) during pain, are a sign of coronary ischemia. A transient S3 (ventricular gallop) or mitral
regurgitation murmur at the apex can occur occasionally with myocardial ischemia. An S4 (atrial gallop)
typically indicates a stressed heart which can be
the result of hypertension, MI, or CAD. Abnormal
rhythms and heart rates are often heard during MI
assessment. ECGs are necessary to identify the specic rhythm.
Percuss and Palpate the Abdomen
Some patients with gastritis have midepigastric tenderness on percussion and palpation. A palpable epigastric
or abdominal mass suggests cancer. A palpable hard
lymph node in the umbilicus points to gastric cancer.
Inspect the Eyes, Nose, and Mouth
Evidence of allergic rhinitis, such as pale boggy nasal
mucosa, clear rhinorrhea, and cobblestone conjunctivae,
suggest allergic eosinophilic esophagitis (AEE). Illtting dentures may be a cause of aerophagia and gas.
The presence of ipsilateral Horner syndrome
(miosis, ptosis, absence of sweating on ipsilateral face
and neck) points to advanced esophageal cancer.
Palpate Supraclavicular Lymph Nodes
Supraclavicular lymphadenopathy points to esophageal, breast, or gastric cancer.
LABORATORY AND DIAGNOSTIC STUDIES
Complete Blood Count
The initial evaluation should include a complete blood
count (CBC) to rule out anemia.
Blood Chemistries
Patients with nausea, vomiting, and epigastric fullness
may also have generalized electrolyte imbalances. If
the history and physical examination suggest the presence of a hepatobiliary condition, liver function tests
should be ordered.
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