++
For further information, see CMDT Part 2-11: Acute Headache
+++
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
++
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
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
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
++
++
Cerebrospinal fluid (CSF) examination
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
++
Sinus CT scan
Noncontrast ...