Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 24-01: Headache + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ 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 + Treatment Download Section PDF Listen +++ ++ See specific headache disorder: Headache, Tension; Headache, Migraine; Polymyalgia Rheumatica & Giant Cell Arteritis; Cough + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Jackson JL et al. Tricyclic and tetracyclic antidepressants for the prevention of frequent episodic or chronic tension-type headache in adults: a systematic review and meta-analysis. J Gen Intern Med. 2017 Dec;32(12):1351–8. [PubMed: 28721535] + +Puledda F et al. An update on migraine: current understanding and future directions. J Neurol. 2017 Sep;264(9):2031–9. [PubMed: 28321564] + +Vukovic-Cvetkovic V et al. Neurostimulation for the treatment of chronic migraine and cluster headache. Acta Neurol Scand. 2019 Jan;139(1):4–17. [PubMed: 30291633]