Headache, Acute

Key Features

Essentials of Diagnosis

• Inquire about

  • Age > 40 years

  • Rapid onset with severe intensity; trauma; onset during exertion

  • Fever; vision changes; neck stiffness

  • HIV infection

  • History of hypertension

  • Neurologic findings (mental status changes, motor or sensory deficits, loss of consciousness)

General Considerations

• In the emergency department, 1% of patients with acute headache have a life-threatening condition

• In the clinician's office, the prevalence of life-threatening conditions is much lower

Clinical Findings

Symptoms and Signs

• Sudden-onset headache that reaches maximal and severe intensity within seconds or a few minutes ("thunderclap headache") suggests subarachnoid hemorrhage

• Headache with uncontrolled hypertension should prompt search for other manifestations of "hypertensive urgency or emergency" (See Hypertensive Urgencies & Emergencies)

• Headache and hypertension in pregnancy may be due to preeclampsia

• Episodic headache with hypertension, palpitations, and sweats may be due to pheochromocytoma

• Other historical features that raise the need for diagnostic testing include headache brought on by

  • Valsalva maneuver

  • Cough

  • Exertion

  • Sexual activity

• Physical examination should include

  • Vital signs

  • Neurologic examination

  • Vision/fundoscopic examination

  • Kernig and Brudzinski signs

• Patients > 60 years old should be examined for possible scalp or temporal artery tenderness, suggesting temporal arteritis

• Diminished visual acuity suggests

  • Glaucoma

  • Temporal arteritis

  • Optic neuritis

• Ophthalmoplegia or visual field defects suggest

  • Venous sinus thrombosis

  • Tumor

  • Aneurysm

• Afferent pupillary defects occur with intracranial masses or optic neuritis

• In the setting of headache and hypertension, acute severe hypertensive retinopathy is indicated by

  • Retinal cotton wool spots

  • Flame hemorrhages

  • Disk swelling

• Ipsilateral ptosis and miosis (Horner syndrome) occur with carotid artery dissection

• Papilledema or absent retinal venous pulsation or both occur with elevated intracranial pressure

• A systematic list called the SNNOOP10 has been developed as a screen for secondary causes of headache (Table 2–7)

Differential Diagnosis

• Causes of headache that require immediate treatment

  • Imminent or completed vascular events (intracranial hemorrhage, thrombosis, vasculitis, malignant hypertension, arterial dissection, cerebral venous thrombosis, transient ischemic attack, or aneurysm)

  • Infections (abscess, encephalitis, meningitis)

  • Intracranial masses causing intracranial hypertension

  • Preeclampsia

  • Carbon monoxide poisoning

Diagnosis

Laboratory Tests

• Cerebrospinal fluid (CSF) examination

  • White blood cell count with differential

  • Red blood cell count

  • Glucose

  • Total protein

  • Gram stain

  • Bacterial culture

  • VDRL

• Erythrocyte sedimentation rate

• Urinalysis

• In suspected cases, obtain CSF polymerase chain reaction test for herpes simplex 2

• In HIV-infected patients, obtain CSF cryptococcal antigen, acid-fast bacillus stain and culture, and complement fixation and culture for coccidioidomycosis

Imaging Studies

• Sinus CT scan

• Noncontrast ...