• Clinical science
  • Clinician

Headache

Summary

Headache is a symptom commonly encountered in everyday clinical practice, and, according to the WHO, one of the ten most common causes of functional disability. It may be primary (e.g., tension-type headaches, migraine) or secondary (e.g., following head trauma or infections) in nature. Although most episodes of headache are harmless, potentially life-threatening causes (e.g., subarachnoid hemorrhage, meningitis) should always be considered. Identifying the cause of headaches is often difficult and requires a detailed clinical history as well as a thorough physical examination. Additional diagnostics, e.g., imaging, are only indicated if headaches persist despite treatment or if specific clinical features are present that are signs of an underlying disease. This learning card gives an overview of the most common types of headache and serves as a guide to diagnosing different headache disorders.

Approach

Approach to management

  1. Check vital signs.
  2. Perform focused history and examination.
  3. If red flags are present:
    • Obtain brain imaging (either CT or MRI brain with and/or without contrast) based on the red flag symptoms. [1]
    • Perform further targeted diagnostics (see below).
  4. If no red flags are present and suspicion for life-threatening causes is low:
    • Perform a detailed history and clinical exam.
    • Consider whether further diagnostic testing is necessary.
  5. Provide supportive care.
  6. Identify and treat the underlying cause.

Red flags for headache [1]

Life-threatening conditions [1]

Definition

Epidemiology

  • Lifetime prevalence: > 90%, with female predominance [3]
  • Most common forms of headache [3]
    • Tension-type headache: 40–80% of cases
    • Migraine: 10% of cases

Epidemiological data refers to the US, unless otherwise specified.

Etiology

See “differential diagnoses” below.

Clinical features

History of present illness

  • Timing
    • Duration of a single episode
    • Frequency
    • Clinical course (e.g., chronic, acute)
  • Nature of the headache
    • Localization
    • Character
    • Intensity
    • Radiation of pain
    • Severity (e.g., impact on patient's life)
  • Triggers and exacerbating factors
    • Altered sleep-wake cycle
    • Physical exertion
    • Stress
    • Certain types of food or alcohol
    • Fluctuations in hormone levels: oral contraceptives; , menstruation
    • Lying down or standing up
    • Recent trauma
  • Associated symptoms

Past medical history, social history, and family history

Physical examination

Consider secondary life-threatening causes if red flags for headache are present!

Diagnostics

Approach [4]

  • Diagnostic evaluation should be performed based on risk stratification and the suspected diagnosis.
    • Low-risk headache: No routine laboratory tests or imaging are recommended.
    • High-risk headache: Consider diagnostic workup based on the suspected diagnosis.
  • Primary headache is a clinical diagnosis and typically does not require laboratory or imaging evaluation.

Risk stratification of headache [4][5]

Clinical features
Low-risk headache
High-risk headache

Laboratory studies

  • There are no routine recommended laboratory studies for headaches. Consider the following based on clinical suspicion:

Imaging [6]

  • Indications
  • Test of choice
    • The initial test of choice is usually a head CT without contrast.
    • See the table below for other imaging modalities to consider.
Recommended initial imaging modality for headache [7]
Initial test of choice Alternatives
Sudden-onset severe headache (i.e., thunderclap headache)
  • CT head without IV contrast
  • CTA with IV contrast
New headache with papilledema
  • MRI head
    • Without contrast
    • Without and with IV contrast
  • CT head without IV contrast
  • CTV head with IV contrast
  • MRV head
    • Without IV contrast
    • Without and with IV contrast
  • CT head with IV contrast
New or worsening headache related to head trauma or accompanied by red flags
  • CT head without IV contrast
  • MRI head
    • Without IV contrast
    • Without and with IV contrast
  • N/A

New primary headache suspected to be of trigeminal autonomic origin

(e.g., cluster headache)

  • MRI head without and with IV contrast
  • MRI head without IV contrast
Chronic headache with new features or change in character, severity, or frequency
  • MRI head
    • Without IV contrast
    • Without and with IV contrast
  • CT head
    • Without and with IV contrast
    • Without IV contrast

Additional diagnostics to consider [6]

The diagnostic modality should be determined by the patient history and clinical presentation. Neuroimaging is usually not indicated for primary or low-risk headaches.

Primary headaches

Tension headache Migraine headache Cluster headache
Sex
  • <
  • <
  • > (3:1)
Duration
  • 30 minutes to a couple of days
  • 4–72 hours
  • 30–180 minutes
  • Short, recurring attacks
Frequency
  • Occasionally to daily
  • Episodic or chronic
  • Occasionally to several times a month
  • 1–3 episodes ever 24 hours
  • Usually occur in a cyclical pattern (clusters)
Localization
  • Holocephalic or bifrontal
  • 60% are unilateral.
  • Mostly unilateral
Character
  • Dull, nonpulsating, band-like or vise-like pain
  • Pulsating, boring/hammering pain
  • Localized to the periorbital and/or temporal region
Intensity
  • Mild to moderate
  • Moderate to severe
  • Severe, agonizing pain
Additional symptoms
  • No autonomic symptoms (vomiting, nausea, phonophobia, or photophobia)
  • Tightness in the posterior neck muscles
  • Pericranial tenderness
Triggers/exacerbating factors
  • Stress
  • Lack of sleep, fatigue
  • Routine activities (e.g., climbing stairs) do not exacerbate symptoms.
  • Stress
  • Fluctuation in hormone levels: oral contraceptives, menstruation
  • Certain types of food (e.g., those containing tyramines or nitrates such as processed meat, chocolate, cheese)
  • Exacerbated by exertion
  • Improved with sleeping/darkness
  • Alcohol
Diagnostic findings
  • Clinical diagnosis
  • Clinical diagnosis [8]
  • Neuroimaging: typically normal findings [9][10]
  • Clinical diagnosis [11]
Acute management

The typical migraine headache is “POUND”: pulsatile, one-day duration, unilateral, nausea, disabling intensity.

Secondary headaches

Diagnosis Clinical features Diagnostic findings Acute management
Meningitis [12][13][14]
  • Classic triad: fever, headache, and neck stiffness (nuchal rigidity)
  • Meningism (e.g., photophobia)
  • Dull, diffuse (holocephalic) headache that worsens over hours/days
  • Altered mental status
  • Nausea, vomiting
  • Seizures
Intracerebral hemorrhage [15][16]
  • Acute, severe, nonspecific headache
  • Focal neurologic signs and symptoms
  • Nausea and vomiting
  • Confusion and loss of consciousness
  • Seizures
Subarachnoid hemorrhage [17]
Subdural hematoma (SDH)
  • CT head without contrast: crescent-shaped, concave, hyperdense hemorrhage that crosses suture lines but not the midline
Epidural hematoma [18]
  • Headache localized to the side of the hematoma
  • Contralateral focal symptoms/hemiplegia
  • Impaired mental status, loss of consciousness, seizures, nausea, and vomiting
  • Nearly half of patients who lose consciousness will have a lucid interval followed by clinical deterioration due to further expansion.
  • CT head without contrast: biconvex, hyperdense lesion
Cerebral venous sinus thrombosis [19]
Giant cell arteritis [21][22][23][24]
  • Unilateral headache over the temporal/occipital area
  • Prominent, tender temporal artery
  • Jaw claudication, scalp tenderness
  • Constitutional symptoms: fever, malaise, fatigue
  • If temporal arteritis is associated with polymyalgia rheumatica: shoulder/pelvic pain, depression, tiredness, fever, weight loss
  • Partial or complete vision loss (unilateral or bilateral), amaurosis fugax, diplopia
Hypertensive crises [25][26]
  • Diffuse (sometimes bifrontal), pulsating headache that is exacerbated by physical activity
  • Hypertension > 180/120 mm Hg
  • Signs of end-organ damage (e.g., chest pain, dyspnea, oliguria, altered mental status)
Ischemic stroke [27][28]
Intracranial space-occupying lesions (e.g., brain tumors) [29][30][31]
Concussion (e.g., mild traumatic brain injury) [32][33][34]
  • Clinical diagnosis
  • CT head without contrast: usually normal
Trigeminal neuralgia [35][36]
  • Paroxysmal , stabbing, unilateral facial pain
  • Tender trigger points
  • No neurologic deficits
  • Clinical diagnosis [36]
  • MRI brain: vascular compression of the trigeminal root
Medication overuse headache
  • Dull, long-lasting headache with variable characteristics
  • History of analgesic overuse
  • Nausea, irritability, difficulty concentrating
  • Clinical diagnosis

Differential diagnoses

Primary headache

Secondary headache

The differential diagnoses listed here are not exhaustive.

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last updated 07/02/2020
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