What are the next steps for a patient with a new onset headache and fibrosis/scarring in the left parietal scalp?

From the Guidelines

For a patient with new onset headache and fibrosis/scarring in the left parietal scalp, the next steps should include a comprehensive neurological evaluation and imaging studies, prioritizing a brain MRI with contrast to rule out underlying pathology, as recommended by recent guidelines 1. The patient's medical history should be thoroughly recorded, and diagnostic criteria for migraine and other headache disorders should be applied, considering differential diagnoses and examining the patient to exclude other causes, as outlined in the diagnosis and management of migraine in ten steps 1. A detailed headache history should be obtained, including onset, duration, character, location, and associated symptoms. Laboratory tests, including complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein, should be ordered to evaluate for inflammatory or infectious processes. If there is concern for giant cell arteritis, particularly in patients over 50, a temporal artery biopsy may be warranted. Pain management should begin with acetaminophen or NSAIDs, such as ibuprofen 400-600mg every 6 hours as needed, while avoiding medication overuse, as suggested by the management of acute migraine headache guidelines 1. The scalp fibrosis should be examined by a dermatologist to determine its etiology, which could include conditions like morphea, radiation-induced fibrosis, or scarring from previous trauma or surgery. Understanding the relationship between the scalp changes and headache is crucial, as the fibrosis could be causing tension headaches through traction on surrounding tissues, or both conditions could be manifestations of an underlying systemic disorder requiring specific treatment. Key considerations in the imaging study include the use of MRI, which serves multiple purposes, including identifying and characterizing focal causative lesions, as well as assessing progression, as highlighted in the ACR appropriateness criteria for seizures and epilepsy 1. The use of intravenous contrast may be useful when images without contrast are not sufficient or if neoplasm or inflammatory condition is suspected. Overall, a comprehensive approach, considering both the headache and the scalp fibrosis, is essential for optimal management and to minimize potential morbidity and mortality.

From the Research

Next Steps for Patient with New Onset Headache and Fibrosis/Scarring in the Left Parietal Scalp

The patient's presentation of a new onset headache with fibrosis/scarring in the left parietal scalp requires a thorough evaluation to determine the underlying cause of the headache.

• The history and neurologic and general physical examinations are crucial in making a diagnosis, as stated in 2.
• Certain historical and examination findings, such as recent head or neck injury, a new, worse, worsening, or abrupt onset headache, and neurologic findings and/or symptoms, increase the likelihood of a secondary headache disorder and the need for diagnostic testing, as mentioned in 2.
• The presence of fibrosis/scarring in the left parietal scalp may indicate a secondary cause of the headache, and further evaluation is necessary to determine the underlying cause.
• Diagnostic studies, such as neuroimaging, cerebrospinal fluid (CSF) examination, and blood tests, may be indicated depending on the patient's history and findings, as stated in 2.
• A magnetic resonance imaging (MRI) brain scan is usually the diagnostic test of choice for most patients, while computed tomography (CT) of the brain is usually obtained in the setting of trauma or the abrupt onset of headache, as mentioned in 2.
• A thorough history and physical examination, along with a comprehensive differential diagnosis, may alert a physician to the diagnosis of a secondary headache, particularly when it is accompanied by certain clinical features, as stated in 3.
• Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated, as mentioned in 3.
• Careful attention to the patient's history and physical examination will guide the diagnostic work-up and management, as stated in 3.

Diagnostic Considerations

• The patient's medical history, age of onset, location of pain, pain characteristics, pain chronology, associated signs and symptoms, and signs of neurologic dysfunction are all important considerations in making a diagnosis, as mentioned in 4.
• The International Headache Society has developed a thorough classification system to aid in the diagnosis of headache, which includes primary disorders of migraine, tension-type headache, and cluster headache, as well as secondary, organic disorders, as stated in 4.
• Establishing an open and honest physician-patient relationship is essential for the proper evaluation and management of headache disorders, as mentioned in 5.
• Obtaining a complete headache and medical history is the most important part of the initial diagnostic evaluation, as stated in 5.
• A thorough neurologic examination must also be performed; if it is normal, there is usually no need for special tests, as mentioned in 5.