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Headache is one of the most common reasons patients seek medical attention. Most patients with recurrent, episodic headaches have a primary headache disorder (ie, not associated with a demonstrable structural abnormality). These disorders include migraine (with or without aura), cluster headache (episodic or chronic), tension-type headache (episodic or chronic), chronic paroxysmal hemicrania, and hemicrania continua. Patients with new-onset, persistent headache may have a secondary headache disorder, due to various intracranial, extracranial, and systemic disorders (see Table 1: Headache: Causes of Secondary Headache and elsewhere in The Manual).
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Table 1
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Causes
of Secondary Headache
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Cause
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Examples
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Extracranial disorders
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Carotid or vertebral artery dissection
Cervical spine disorders
CSF leak with low-pressure headache
Dental disorders (infection, temporomandibular joint dysfunction)
Glaucoma
Sinusitis
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Intracranial disorders
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Brain tumors and mass lesions
Chiari type I malformation
Hemorrhage (intracerebral, subdural, subarachnoid)
Idiopathic intracranial hypertension
Infections (eg, cerebritis, encephalitis, meningitis)
Obstructive hydrocephalus
Vascular disorders (eg, moyamoya disease, vascular malformations, vasculitis, venous sinus thrombosis)
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Systemic disorders
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Accelerated hypertension
Bacteremia
Fever
Hypercapnia
Hypoxia (including altitude sickness)
Viremia
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Drugs and toxins
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Analgesic rebound
Caffeine withdrawal
Hormones (eg, estrogen)
Nitrates
Proton pump inhibitors
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Evaluation
History and physical examination usually suggest a diagnosis and guide subsequent testing.
History:
Headache characteristics helpful in diagnosis include age at onset; frequency, duration, location, and severity of the headache; factors associated with initiation, exacerbation, or remission; accompanying symptoms (eg, fever, stiff neck, nausea, vomiting, mental status changes, photophobia); and preceding conditions (ie, head trauma, cancer, immunosuppression).
Recurrent episodic, severe headache with onset in adolescence or early adulthood suggests a primary headache disorder. Sudden-onset, very severe (thunderclap) headache suggests possible subarachnoid hemorrhage. A subacute, progressively worsening daily headache suggests a space-occupying lesion. Headache with onset after age 50 and accompanied by scalp tenderness, jaw claudication, or visual changes suggests temporal arteritis.
Confusion, seizure, fever, or focal neurologic symptoms suggest a serious cause requiring further evaluation.
History of a coexisting disorder may suggest the cause of headache; eg, recent head trauma, hemophilia, alcoholism, or anticoagulant therapy may suggest subdural hematoma.
Physical
examination:
A neurologic examination (see Approach to the Neurologic Patient), including ophthalmoscopy, mental status examination, and evaluation for meningeal signs, is necessary. Recurring episodic headaches in a patient who appears well and has a normal neurologic examination rarely have an ominous cause.
Neck stiffness with flexion (but not rotation) indicates meningeal irritation due to infection or subarachnoid hemorrhage; fever suggests infection, but low-grade fever may occur with hemorrhage. Tenderness on palpation of the temporal arteries in patients > 50 suggests temporal arteritis. Papilledema indicates increased intracranial pressure, which may be due to idiopathic intracranial hypertension, accelerated hypertension, a mass lesion, or sagittal sinus thrombosis. Focal neurologic symptoms or mental status changes typically accompany structural lesions (eg, tumor, stroke, abscess, hematoma).
Testing:
Imaging and laboratory tests are necessary only if history or examination findings are worrisome or abnormal.
Patients requiring very urgent CT or MRI to look for hemorrhage, increased intracranial pressure, and other structural causes of headache include those with
Because an unremarkable CT scan does not entirely rule out subarachnoid hemorrhage, meningitis, encephalitis, or inflammatory processes, lumbar puncture is indicated when these disorders are suspected.
Patients requiring prompt but not immediate imaging include those with a change in prior headache pattern, new onset of headache after age 50, systemic symptoms (eg, weight loss), secondary risk factors (eg, cancer, HIV, head trauma), or chronic unexplained headache. For these patients, MRI (typically using gadolinium with magnetic resonance angiography or venography) is preferred; it can show many unusual but important causes of headache that can be missed on CT (eg, carotid dissection, cerebral vein thrombosis, pituitary apoplexy, vascular malformations, cerebral vasculitis, Chiari type I malformation).
Patients with unusual, persistent headaches may also require lumbar puncture to check for chronic meningitis (eg, infectious, granulomatous, neoplastic) and idiopathic intracranial hypertension (assessed by CSF pressure).
Other tests are used if specific disorders are suspected (eg, ESR for temporal arteritis, intraocular pressure measurement for glaucoma, dental x-rays for tooth abscess).
Last full review/revision November 2005
Content last modified November 2005
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