Approach to the Patient With Headache

History of present illness includes questions about the headache's characteristics:

• Location

• Duration

• Severity

• Onset (eg, sudden, gradual)

• 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. Patients are asked whether headaches occur only when standing; such headaches are a concern because they may be caused by a cerebrospinal fluid (CSF) leak or postural orthostatic tachycardia syndrome (POTS). 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, the following are noted:

• Age at onset

• Frequency of episodes

• Temporal pattern (including any relationship to phase of menstrual cycle)

• Response to treatments (including over-the-counter treatments)

Review of systems should seek symptoms suggesting a cause, including

• Vomiting: Migraine or increased intracranial pressure

• Fever: Infection (eg, encephalitis, meningitis, sinusitis)

• Red eye and/or visual symptoms (halos, blurring): Acute angle-closure glaucoma

• Visual field deficits, diplopia, or blurring vision: Ocular migraine, brain mass lesion, or idiopathic intracranial hypertension

• Lacrimation and facial flushing: Cluster headache

• Rhinorrhea: Sinusitis

• Pulsatile tinnitus: Idiopathic intracranial hypertension

• Preceding aura: Migraine

• Focal neurologic deficit: Encephalitis, meningitis, intracerebral hemorrhage, subdural hematoma, tumor, or other mass lesion

• Seizures: Encephalitis, tumor, or other mass lesion

• Syncope at headache onset: Subarachnoid hemorrhage

• Myalgias and/or vision changes (in people> 50 years): Giant cell arteritis

Past medical historyDisorders Causing Secondary Headache

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 a headache questionnaire that covers most of the relevant medical history pertinent to diagnosis of headache. Patients may complete the questionnaire before their visit and bring the results with them.

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 retinal 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.

The following findings are of particular concern:

• Neurologic symptoms or signs (eg, altered mental status, weakness, diplopia, papilledema, focal neurologic deficits)

• Severe hypertension

• Immunosuppression or cancer

• Meningismus

• Onset of headache after age 50

• Thunderclap headache (severe headache that peaks within a few seconds)

• Symptoms of giant cell arteritis (eg, visual disturbances, jaw claudication, fever, weight loss, temporal artery tenderness, proximal myalgias)

• Systemic symptoms (eg, fever, weight loss)

• Progressively worsening headache

• Red eye and halos around lights

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 Some Characteristics of Headache Disorders by Cause).

Red flag findings suggest a cause (see table Matching Red Flag Findings With a Cause for Headache).

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.

MRI (and perhaps magnetic resonance angiography [MRA]) should be done as soon as possible in patients with any of the following findings:

• Thunderclap headache

• Altered mental status

• Meningismus

• Papilledema

• Acute focal neurologic deficit

If MRI is not immediately available, CT can be used.

Also, neuroimaging, usually MRI, should be done if patients have any of the following:

• Focal neurologic deficit of subacute or uncertain onset

• New onset

• Age > 50 years

• Cancer

• HIV infection or AIDS

• Change in an established headache pattern

• Diplopia

In addition, if meningitis, subarachnoid hemorrhage, encephalitis, or any cause of meningismus is being considered, lumbar puncture and cerebrospinal fluid (CSF) analysis should be done, if not contraindicated by imaging results. Patients with a thunderclap headache require CSF analysis even if imaging and examination findings are normal as long as lumbar puncture is not contraindicated by imaging results. CSF analysis is also usually indicated if patients with headache are immunosuppressed or if they have papilledema.

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.

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be determined 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).