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Headache

Last updated: June 24, 2022

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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 article gives an overview of the most common types of headache and serves as a guide to diagnosing different headache disorders.

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.

Headache red flags (SNOOP10) [1][2]

The original mnemonic, SNOOP has more recently been expanded to cover the following total of 15 red flags:

  • Systemic symptoms (e.g., fever, signs of meningitis, myalgia, malaise)
  • Neoplasm in history
  • Neurological deficits/dysfunction (e.g., altered mental status, seizures) [3]
  • Onset of headache is sudden or abrupt
  • Older age at onset (> 50 years)
  • Pattern changes of headache or recent onset
  • Positional headache
  • Precipitated by sneezing, coughing, or exercise
  • Papilledema and other signs of increased ICP
  • Progressive headache and atypical features
  • Pregnancy or postpartum period
  • Pain of the eye with autonomic features and visual deficits
  • Posttraumatic onset
  • Pathology of the immune system (especially due to HIV)
  • Painkiller overuse or new drug at onset of headache

A new or progressive headache in a patient aged > 50 years may indicate tumor or hemorrhage and should always be treated as a high-risk headache.

Life-threatening conditions [1]

  • Lifetime prevalence: > 90%, with female predominance (except cluster headache) [5]
  • Most common forms of headache [5]
    • Tension-type headache: 40–80% of cases
    • Migraine: 10% of cases

Among patients presenting to the emergency department with headaches, primary headache (most frequently migraine) is the most common type, but up to 5% may have a secondary headache with a serious life-threatening cause. [6]

Epidemiological data refers to the US, unless otherwise specified.

See “Differential diagnoses” below.

History of present illness

Maintain a high index of suspicion for secondary headache in patients with a new, sudden-onset severe headache.

Past medical history, social history, and family history

Physical examination

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

Approach [7]

  • Check vital signs, obtain a history, and perform a physical and neurological examination.
  • Determine the need for further testing 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.

In patients who are unstable or have signs of increased ICP, diagnostics should not delay stabilization (e.g., ABCDE approach) and neuroprotective measures.

The diagnostic modality should be determined by the patient history and clinical presentation. Primary headache is a clinical diagnosis and typically does not require laboratory or imaging evaluation.

Risk stratification of headache [7][8]

Clinical features
Low-risk headache
High-risk headache

Response to analgesics should not be used for risk stratification! Pursue a diagnostic workup for high-risk features even if headache improves with initial treatment. [10][11]

In the emergency department, use the Ottawa subarachnoid hemorrhage (SAH) clinical decision rule to rule out SAH in patients presenting with rapid onset headache and a normal neurological examination. [12]

Laboratory studies

Imaging [12][13]

Recommended initial imaging modality for headache [14]
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

In patients presenting to the emergency department with acute headache and a normal neurological examination, a negative head CT without contrast indicates that the diagnosis of SAH is unlikely, even when performed < 6 hours from the onset of headache (see “Diagnostics” in “Subarachnoid hemorrhage.”) [12]

Avoid imaging in patients presenting with a recurrent known migraine unless new concerning features are present, e.g., seizures, focal neurological deficits, or recent change in headache pattern.

Additional diagnostics to consider [13]

In the emergency department, if SAH is still suspected despite a normal head CT without contrast, either LP or CTA can be used as a second-line test to safely rule out the diagnosis (see “Diagnostics” in “Subarachnoid hemorrhage”). [12]

In patients with suspected meningitis or encephalitis, do not delay lumbar puncture unless the patient meets the criteria for imaging prior to LP.

Types of primary headaches [15]
Characteristics Tension-type headache Migraine headache Cluster headache

Mixed type headache [4]
Epidemiology
Triggers/exacerbating factors
Clinical features Attack duration
  • 30 minutes to 7 days
  • 4–72 hours
  • 15–180 minutes
  • Short, recurring attacks
  • Hours to days
Frequency
  • Occasionally to daily (usually at the end of the day)
  • Episodic or chronic
  • Occasionally to several times a month
  • Episodic or chronic
  • 1–3 episodes every 24 hours
  • Usually occur in a cyclical pattern (cluster periods) with remissions lasting ≥ 3 months (i.e., episodic CH), but may also occur with remissions lasting < 3 months or no remission (i.e., chronic CH)
  • Episodic or chronic
Localization
  • 60% of cases are unilateral.
  • Exclusively unilateral
  • Localized to the periorbital and/or temporal region
Character
  • Dull, nonpulsating, band-like or vise-like pain
  • Constant
  • Pulsating, boring/hammering pain
  • Often burning or piercing pain
  • Attacks develop within minutes
  • Often wakes patients up from sleep
Intensity
  • Mild to moderate
  • Moderate to severe
  • Severe, agonizing pain
  • Mild to severe
Additional symptoms
Diagnostics
Management

“POUND:“ pulsatile, one-day duration, unilateral, nausea, and disabling intensity are the typical features of migraine headache.

In the emergency department, nonopioid pain medications are preferred for the treatment of acute primary headaches. [12]

Diagnosis Clinical features Diagnostic findings Acute management
Meningitis [18][19][20]
Intracerebral hemorrhage [21][22]
Subarachnoid hemorrhage [23]
Subdural hematoma (SDH)
  • CT head without contrast: crescent-shaped, concave, hyperdense hemorrhage that crosses suture lines but not the midline
Epidural hematoma [24]
  • CT head without contrast: biconvex, hyperdense lesion
Cerebral venous sinus thrombosis [25]
Giant cell arteritis [27][28][29][30]
Hypertensive crises [31][32]
Ischemic stroke [33][34]
Intracranial space-occupying lesions (e.g., brain tumors) [35][36][37]
Concussion (e.g., mild traumatic brain injury) [38][39][40]
Acute angle-closure glaucoma

[41][42]
Trigeminal neuralgia [44][45]
  • Paroxysmal (seconds to 2 minutes) and stabbing pain
  • Unilateral facial pain, strictly localized to the distribution of the branches of the trigeminal nerve
  • Frequency and intensity of episodes usually increase over time
  • Tender trigger points
  • Triggered by chewing, talking, cold, and touching specific areas of the face
  • No neurological deficits
Medication overuse headache
  • Headache with variable characteristics
  • History of analgesic overuse
  • Autonomic symptoms (e.g., nausea)
  • Cognitive or behavioral symptoms (e.g., comorbid depression)

Consider eye examination in patients with unexplained acute-onset severe headache with nausea and vomiting to evaluate for signs of acute angle-closure glaucoma.

Primary headache

Secondary headache

The differential diagnoses listed here are not exhaustive.

Most patients with primary headaches and benign secondary headaches can be managed as outpatients. [6]

Indications for hospitalization

Discharge from the emergency department

Discharge home is appropriate once life-threatening causes of headache have been ruled out and the patient's symptoms improve with initial treatment (even if the headache is not completely resolved). [6]

  • Consider appropriate prescription of analgesics and preventive medication based on the underlying diagnosis.
  • Provide patient counseling and education.
  • Ensure outpatient primary care follow-up, especially for patients at high risk of early recurrence. [10]
  • Consider referral to neurology or a specialized headache clinic.

Appropriate discharge planning is important to ensure ongoing care and reduce unnecessary return visits to the emergency department e.g., due to recurrent headaches or incomplete treatment.

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