Headache is such a common complaint and can occur for so many different reasons that its proper evaluation may be difficult. New, severe, or acute headaches are more likely than chronic headaches to relate to an intracranial disorder; the approach to such headaches is discussed in Chapter 2. Chronic headaches may be primary or secondary to another disorder. Common primary headache syndromes include migraine, tension-type headache, and cluster headache. Important secondary causes to consider include intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, temporomandibular joint dysfunction, sinusitis, hypertension, depression, and a wide variety of general medical disorders. Although underlying structural lesions are not present in most patients presenting with headache, it is nevertheless important to bear this possibility in mind. About one-third of patients with brain tumors, for example, present with a primary complaint of headache.
The intensity, quality, and site of pain—and especially the duration of the headache and the presence of associated neurologic symptoms—may provide clues to the underlying cause. Migraine headaches are often described as pulsating or throbbing; a sense of tightness or pressure is common with tension headache. Sharp lancinating pain suggests a neuritic cause; ocular or periorbital icepick-like pains occur with migraine or cluster headache; and a dull or steady headache is typical of an intracranial mass lesion. Ocular or periocular pain suggests an ophthalmologic disorder; band-like pain is common with tension headaches; and lateralized headache is common with migraine or cluster headache. In patients with sinusitis, there may be tenderness of overlying skin and bone. With intracranial mass lesions, headache may be focal or generalized; in patients with trigeminal or glossopharyngeal neuralgia, the pain is localized to one of the divisions of the trigeminal nerve or to the pharynx and external auditory meatus, respectively.
Inquiry should be made of precipitating factors. Recent sinusitis, dental surgery, head injury, or symptoms suggestive of a systemic viral infection may suggest the underlying cause. Migraine may be exacerbated by emotional stress, fatigue, foods containing nitrite or tyramine, or the menstrual period. Alcohol may precipitate cluster headache. Temporomandibular joint dysfunction causes headache or facial pain that comes on with chewing; trigeminal or glossopharyngeal neuralgia may also be precipitated by chewing, and masticatory claudication sometimes occurs with giant cell arteritis. Cough-induced headache occurs with structural lesions of the posterior fossa, but in many instances no specific cause can be found.
The timing of symptoms is important. Headaches are typically worse on awakening in patients with an intracranial mass or sleep apnea. Cluster headaches tend to occur at the same time each day or night. Tension headaches are worse with stress or at the end of the day.
Associated symptoms may also be helpful. Nausea; sensitivity to light, sound, and exertion; and a proclivity to retreat to a dark, quiet room typify migraine. Anxiety, agitation, and even suicidality may accompany cluster headache. Other accompanying symptoms may point to specific disorders.