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 Headache: A Merck Manual of Patient Symptoms podcast
Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical attention.
Pathophysiology
Headache is due to activation of pain-sensitive structures in or around the brain, skull, face, sinuses, or teeth.
Etiology
Headache may occur as a primary disorder or be secondary to another disorder. Primary headache disorders include migraine, cluster headache (including chronic paroxysmal hemicrania and hemicrania continua), and tension-type headache. Secondary headache has numerous causes (see Table 1: Headache: Disorders Causing Secondary Headache ).
Overall, the most common causes of headache are
Some causes of headache are common; others are important to recognize because they are dangerous, require specific treatment, or both (see Table 2: Headache: Some Characteristics of Headache Disorders by Cause).
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Table 1
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| Disorders Causing Secondary Headache |
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Cause
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Examples
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Extracranial disorders
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Carotid or vertebral artery dissection (which also causes neck pain)
Dental disorders (eg, infection, temporomandibular joint dysfunction)
Glaucoma
Sinusitis
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Intracranial disorders
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Brain tumors and other masses
Chiari type I malformation
CSF leak with low-pressure headache
Hemorrhage (intracerebral, subdural, subarachnoid)
Idiopathic intracranial hypertension
Infections (eg, abscess, encephalitis, meningitis, subdural empyema)
Meningitis, noninfectious (eg, carcinomatous, chemical)
Obstructive hydrocephalus
Vascular disorders (eg, vascular malformations, vasculitis, venous sinus thrombosis)
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Systemic disorders
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Acute severe hypertension
Bacteremia
Fever
Giant cell arteritis
Hypercapnia
Hypoxia (including altitude sickness)
Viral infections
Viremia
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Drugs and toxins
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Analgesic overuse
Caffeine withdrawal
Carbon monoxide
Hormones (eg, estrogen)
Nitrates
Proton pump inhibitors
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Table 2
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| Some Characteristics of Headache Disorders by Cause |
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Cause
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Suggestive Findings
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Diagnostic Approach
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Primary headache disorders*
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Cluster headache
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Unilateral orbitotemporal attacks at the same time of day
Deep, severe, lasting 30–180 min
Often with lacrimation, facial flushing, or Horner syndrome; restlessness
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Clinical evaluation
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Migraine headache
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Frequently unilateral and pulsating, lasting 4–72 h
Occasionally with aura, nausea, photophobia, sonophobia, or osmophobia
Worse with activity, preference to lie in the dark, resolution with sleep
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Clinical evaluation
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Tension-type headache
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Frequent or continuous, mild, bilateral, and viselike occipital or frontal pain that spreads to entire head
Worse at end of day
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Clinical evaluation
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Secondary headache
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Acute angle-closure glaucoma
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Unilateral
Halos around lights, decreased visual acuity, conjunctival injection, vomiting
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Tonometry
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Encephalitis
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Fever, altered mental status, seizures, focal neurologic deficits
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MRI, CSF analysis
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Giant cell arteritis
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Age > 55
Unilateral throbbing pain, pain when combing hair, visual disturbances, jaw claudication, fever, weight loss, sweats, temporal artery tenderness, proximal myalgias
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ESR, temporal artery biopsy, usually neuroimaging
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Idiopathic intracranial hypertension
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Migraine-like headache, diplopia, pulsatile tinnitus, loss of peripheral vision, papilledema
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Neuroimaging (preferably MRI with magnetic resonance venography), followed by measurement of CSF opening pressure
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Intracerebral hemorrhage
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Sudden onset
Vomiting, focal neurologic deficits, altered mental status
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Neuroimaging
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Meningitis
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Fever, meningismus, altered mental status
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CSF analysis, often preceded by CT
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Sinusitis
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Positional facial or tooth pain, fever, purulent rhinorrhea
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Clinical evaluation, sometimes CT
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Subarachnoid hemorrhage
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Peak intensity a few seconds after headache onset (thunderclap headache)
Vomiting, syncope, obtundation, meningismus
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Neuroimaging, followed by CSF analysis if it is not contraindicated and imaging is not diagnostic
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Subdural hematoma (chronic)
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Sleepiness, altered mental status, hemiparesis, loss of spontaneous venous pulsations, papilledema
Presence of risk factors (eg, older age, coagulopathy, dementia, anticoagulant use, ethanol abuse)
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Neuroimaging
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Tumor or mass
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Eventually altered mental status, seizures, vomiting, diplopia when looking laterally, loss of spontaneous venous pulsations or papilledema, focal neurologic deficits
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Neuroimaging
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* Primary headaches are usually recurrent.
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Evaluation
Evaluation focuses on determining whether a secondary headache is present and checking for symptoms that suggest a serious cause. If no cause or serious symptoms are identified, evaluation focuses on diagnosing primary headache disorders.
History
History of present illness includes questions about headache location, duration, severity, onset (eg, sudden, gradual), and quality (eg, throbbing, constant, intermittent, pressure-like). Exacerbating and remitting factors (eg, head position, time of day, sleep, light, sounds, physical activity, odors, chewing) are noted. If the patient has had previous or recurrent headaches, the previous diagnosis (if any) needs to be identified, and whether the current headache is similar or different needs to be determined. For recurrent headaches, age at onset, frequency of episodes, temporal pattern (including any relationship to phase of menstrual cycle), and response to treatments (including OTC treatments) are noted.
Review of systems should seek symptoms suggesting a cause, including
Past medical history should identify risk factors for headache, including exposure to drugs, substances (particularly caffeine), and toxins (see Table 1: Headache: Disorders Causing Secondary Headache), recent lumbar puncture, immunosuppressive disorders or IV drug use (risk of infection); hypertension (risk of brain hemorrhage); cancer (risk of brain metastases); and dementia, trauma, coagulopathy, or use of anticoagulants or ethanol (risk of subdural hematoma).
Family and social history should include any family history of headaches, particularly because migraine headache may be undiagnosed in family members.
To streamline data collection, clinicians can ask patients to fill out an online headache questionnaire that covers most of the relevant medical history pertinent to diagnosis of headache; it is available at ProMyHealth. Patients may complete the questionnaire before their visit and bring the results with them.
Physical examination
Vital signs, including temperature, are measured. General appearance (eg, whether restless or calm in a dark room) is noted. A general examination, with a focus on the head and neck, and a full neurologic examination are done.
The scalp is examined for areas of swelling and tenderness. The ipsilateral temporal artery is palpated, and both temporomandibular joints are palpated for tenderness and crepitance while the patient opens and closes the jaw.
The eyes and periorbital area are inspected for lacrimation, flushing, and conjunctival injection. Pupillary size and light responses, extraocular movements, and visual fields are assessed. The fundi are checked for spontaneous venous pulsations and papilledema. If patients have vision-related symptoms or eye abnormalities, visual acuity is measured. If the conjunctiva is red, the anterior chamber and cornea are examined with a slit lamp if possible, and intraocular pressure is measured.
The nares are inspected for purulence. The oropharynx is inspected for swellings, and the teeth are percussed for tenderness.
Neck is flexed to detect discomfort, stiffness, or both, indicating meningismus. The cervical spine is palpated for tenderness.
Red flags
The following findings are of particular concern:
Interpretation of findings
If similar headaches recur in patients who appear well and have a normal examination, the cause is rarely ominous. Headaches that have recurred since childhood or young adulthood suggest a primary headache disorder. If headache type or pattern clearly changes in patients with a known primary headache disorder, secondary headache should be considered.
Most single symptoms of primary headache disorders other than aura are nonspecific. A combination of symptoms and signs is more characteristic (see Table 2: Headache: Some Characteristics of Headache Disorders by Cause).
Red flag findings suggest a cause (see Table 3: Headache: Matching Red Flag Findings with a Cause for Headache).
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Table 3
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| Matching Red Flag Findings with a Cause for Headache |
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Suggestive Findings
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Causes
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Neurologic symptoms or signs (eg, altered mental status, confusion, neurogenic weakness, diplopia, papilledema, focal neurologic deficits)
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Encephalitis, subdural hematoma, subarachnoid or intracerebral hemorrhage, tumor, other intracranial mass, increased intracranial pressure
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Immunosuppression or cancer
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CNS infection, metastases
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Meningismus
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Meningitis, subarachnoid hemorrhage, subdural empyema
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Onset of headache after age 50
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Increased risk of a serious cause (eg, tumor, giant cell arteritis)
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Thunderclap headache (severe headache that peaks within a few seconds)
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Subarachnoid hemorrhage
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Combination of fever, weight loss, visual disturbances, jaw claudication, temporal artery tenderness, and proximal myalgias
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Giant cell arteritis
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Systemic symptoms (eg, fever, weight loss)
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Sepsis, hyperthyroidism, cancer
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Progressively worsening headache
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Secondary headache
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Red eye and halos around lights
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Acute angle-closure glaucoma
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Testing
Most patients can be diagnosed without testing. However, some serious disorders may require urgent or immediate testing. Some patients require tests as soon as possible. CT (or MRI) should be done in patients with any of the following findings:
In addition, if meningitis, subarachnoid hemorrhage, or encephalitis is being considered, lumbar puncture and CSF analysis should be done, if not contraindicated by imaging results.
Tonometry should be done if findings suggest acute narrow-angle glaucoma (eg, visual halos, nausea, corneal edema, shallow anterior chamber).
Other testing should be done within hours or days, depending on the acuity and seriousness of findings and suspected causes.
Neuroimaging, usually MRI, should be done if patients have any of the following:
ESR should be done if patients have visual symptoms, jaw or tongue claudication, temporal artery signs, or other findings suggesting giant cell arteritis.
CT of the paranasal sinuses is done to rule out complicated sinusitis if patients have a moderately severe systemic illness (eg, high fever, dehydration, prostration, tachycardia) and findings suggesting sinusitis (eg, frontal, positional headache, epistaxis, purulent rhinorrhea).
Lumbar puncture and CSF analysis are done if headache is progressive and findings suggest idiopathic intracranial hypertension (eg, transient obscuration of vision, diplopia, pulsatile intracranial tinnitus) or chronic meningitis (eg, persistent low-grade fever, cranial neuropathies, cognitive impairment, lethargy, vomiting, focal neurologic deficits).
Treatment
Treatment of headache is directed at the cause.
Geriatrics Essentials
New-onset headache after age 50 should be considered a secondary disorder until proven otherwise.
Key Points
Last full review/revision November 2012 by Stephen D. Silberstein, MD
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