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Key Features

Essentials of Diagnosis

  • Severe headache in a previously well patient is more likely than chronic headache to relate to an intracranial disorder such as hemorrhage or meningitis

  • Headaches worse on awakening may indicate intracranial mass or sleep apnea

General Considerations

  • Primary headache syndromes include tension, migraine, or cluster

  • Secondary causes

    • Intracranial lesions

    • Head injury

    • Cervical spondylosis

    • Dental or ocular disease

    • Temporomandibular joint dysfunction

    • Sinusitis

    • Hypertension

    • Depression

  • Possibility of underlying structural lesions is important because about one-third of patients with brain tumors have a primary complaint of headache

Clinical Findings

Symptoms and Signs

Tension-type headache

  • Band-like pain is common

  • Sense of tightness or pressure is common

  • Worsens with stress and at end of day

Migraine

  • Often pulsating or throbbing

  • May be ocular or periorbital icepick-like pain

  • Lateralized pain is common

Cluster headache

  • Ocular or icepick-like pain

  • Lateralized pain is common

  • Tends to occur at the same time each day or night

Cranial neuralgias

  • Sharp lancinating pain may be suggestive

  • Pain localized to one of the divisions of the trigeminal nerve or to the external auditory meatus or pharynx, respectively, in trigeminal or glossopharyngeal neuralgia

Sinusitis-related headache

  • May cause tenderness of overlying skin and bone

Intracranial mass lesion–related headache

  • Typically dull or steady pain

  • Pain may be worse in the morning

  • Pain may be localized or general

Differential Diagnosis

Intracranial

  • Migraine

  • Cluster headache

  • Intracranial tumor

  • Subarachnoid hemorrhage

  • Meningitis

  • Brain abscess

  • Temporal (giant cell) arteritis

  • Hypertension

  • Caffeine, alcohol, or drug withdrawal

  • Pseudotumor cerebri

  • Subdural hemorrhage

  • Cerebral ischemia

  • Arterial dissection (carotid or vertebral)

  • Arteriovenous malformation

  • Head injury

  • Lumbar puncture

  • Venous sinus thrombosis (intracranial venous thrombosis)

  • Postlumbar puncture

  • Carbon monoxide poisoning

Extracranial

  • Systemic infections

  • Tension headache

  • Cervical arthritis

  • Glaucoma

  • Dental abscess

  • Sinusitis

  • Otitis media

  • Temporomandibular joint (TMJ) syndrome

  • Depression

  • Somatoform disorder (somatization)

  • Trigeminal neuralgia

  • Glossopharyngeal neuralgia

Diagnosis

Laboratory Tests

  • Cerebrospinal fluid examination if a meningeal infection or subarachnoid hemorrhage is considered

Imaging Studies

  • Cranial MRI or CT scan to exclude an intracranial mass lesion in patients with

    • A progressive headache disorder

    • New onset of headache in middle or later life

    • Headaches that disturb sleep or are related to exertion

    • Headaches that are associated with neurologic symptoms or a focal neurologic deficit

Diagnostic Procedures

  • Inquire about precipitating and exacerbating factors

  • Precipitating factors include recent sinusitis or hay fever, dental surgery, head injury, and symptoms suggestive of a systemic viral infection

  • Alcohol is a ...

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