Headache

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

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

• Idiopathic intracranial hypertension (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

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 precipitating factor for cluster headache

• Chewing as a precipitating factor is associated with TMJ dysfunction, trigeminal or glossopharyngeal neuralgia, and giant cell arteritis

• Cough-induced headache occurs with structural lesions of the posterior fossa, but a specific cause is frequently unidentifiable

• Exacerbating factors for migraine include emotional stress, fatigue, foods containing nitrite or tyramine, and menses

• See specific headache disorder: Headache, Tension; Headache, Migraine; Polymyalgia Rheumatica & Giant Cell Arteritis; Cough

When to Refer

• Thunderclap onset

• Increasing headache unresponsive to simple measures

• History of trauma, hypertension, fever, visual changes

• Presence of neurologic signs or of scalp tenderness

When to Admit

• Suspected subarachnoid hemorrhage or structural intracranial lesion

• Depends on the underlying cause