Evaluation of Headache in Adults

Evaluation of headache in adults
http://www.uptodate.com/contents/evaluation-of-headache-in-adults?to...
Official reprint from UpToDate

www.uptodate.com 2015 UpToDate

Authors
Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD
Section Editor
Jerry W Swanson, MD
Deputy Editor
John F Dashe, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2015. | This topic last updated: Jun 02, 2015.
INTRODUCTION Headache is among the most common medical complaints. An overview of the approach to
the patient with headache is presented here. The approach to adults presenting with headache in the emergency
department is reviewed elsewhere. (See "Evaluation of the adult with headache in the emergency department".)
The clinical features and management of specific primary headache syndromes are discussed separately. (See
"Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Tension-type headache in
adults: Pathophysiology, clinical features, and diagnosis" and "Cluster headache: Epidemiology, clinical features,
and diagnosis".)
EPIDEMIOLOGY AND CLASSIFICATION As many as 90 percent of all benign headaches fall under a few
categories, including migraine, tension-type, cluster, and chronic daily headache. While episodic tension-type
headache is the most frequent headache type in population-based studies, migraine is the most common
diagnosis in patients presenting to primary care physicians with headache. The one-year prevalence of episodic
tension-type headache (TTH) is approximately 65 percent (see "Tension-type headache in adults:
Pathophysiology, clinical features, and diagnosis", section on 'Epidemiology'), but most people with tension-type
headache do not present to physicians for care. As an example, a study of two primary care units in Brazil found
that migraine was the most prevalent primary headache disorder, accounting for 45 percent of patients reporting
headache as a single symptom [1].
Cluster headache typically leads to significant disability and most of these patients will come to medical attention.
However, cluster headache remains an uncommon diagnosis in primary care settings because of overall low
prevalence in the general population (<1 percent). (See "Cluster headache: Epidemiology, clinical features, and
diagnosis", section on 'Epidemiology'.)
Clinicians can easily become familiar with the most common primary headache disorders and how to distinguish
them (table 1).
Migraine Migraine is a disorder of recurrent attacks. The headache of migraine is often but not always
unilateral and tends to have a throbbing or pulsatile quality. Accompanying features may include nausea,
vomiting, photophobia, or phonophobia during attacks. (See "Pathophysiology, clinical manifestations, and
diagnosis of migraine in adults".)
Migraine trigger factors (table 2) may include stress, menstruation, visual stimuli, weather changes, nitrates,
fasting, wine, sleep disturbances, and aspartame, among others. (See "Pathophysiology, clinical manifestations,
and diagnosis of migraine in adults", section on 'Precipitating and exacerbating factors'.)
Tension-type headache The typical presentation of a TTH attack is that of a mild to moderate intensity,
bilateral, nonthrobbing headache without other associated features. Pure TTH is a rather featureless headache.
(See "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis".)
Cluster headache Cluster headache belongs to a group of idiopathic headache entities, the trigeminal
autonomic cephalalgias (table 3), all of which involve unilateral, often severe headache attacks and typical
accompanying autonomic symptoms. Cluster headache is characterized by attacks of severe unilateral orbital,
supraorbital, or temporal pain accompanied by autonomic phenomena. Unilateral autonomic symptoms are
ipsilateral to the pain and may include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal
congestion. Attacks usually last 15 to 180 minutes. (See "Cluster headache: Epidemiology, clinical features, and
diagnosis".)
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Cluster headache may sometimes be confused with a life-threatening headache, since the pain from a cluster
headache can reach full intensity within minutes. However, cluster headache is transient, usually lasting less
than one to two hours.
Secondary headache Physicians who evaluate patients with headache should be alert to signs that suggest
a serious underlying disorder. (See 'Danger signs' below and 'Patient settings' below.)
In the Brazilian primary care study, 39 percent of patients presenting with headache had a headache that was
due to a systemic disorder (most commonly fever, acute hypertension, and sinusitis), and 5 percent had a
headache that was due to a neurologic disorder (most commonly post-traumatic headache, headaches
secondary to cervical spine disease, and expansive intracranial processes) [1].
Misconceptions A number of misconceptions may hinder headache evaluation and diagnosis.
Although sinus headache is commonly diagnosed by physicians and self-diagnosed by patients, acute or
chronic sinusitis appears to be an uncommon cause of recurrent headaches, and many patients presenting
with sinus headache turn out to have migraine [2-4]. (See 'Sinus symptoms' below.)
Patients frequently attribute headaches to eye strain. However, an observational study suggested that
headaches are only rarely due to refractive error alone [5]. Nevertheless, correcting vision may improve
headache symptoms in some of these patients.
There is a common belief, particularly among patients, that hypertension can cause headaches. While this
is true in the case of hypertensive emergencies, it is probably not true for typical migraine or tension
headaches. As an example, a report from the Physicians' Health Study of 22,701 American male
physicians ages 40 to 84 years analyzed various risk factors for cerebrovascular disease and found no
difference in the percentage of men with a history of hypertension in the migraine and nonmigraine groups
[6]. Furthermore, a prospective study of 22,685 adults in Norway found that high systolic and diastolic
pressures were actually associated with a reduced risk of nonmigrainous headache [7].
EVALUATION The appropriate evaluation of headache complaints includes the following:
Rule out serious underlying pathology and look for other secondary causes of headache.
Determine the type of primary headache using the patient history as the primary diagnostic tool (table 1).
There may be overlap in symptoms, particularly between migraine and tension-type headache and between
migraine and some secondary causes of headache such as sinus disease.
A systematic case history is the single most important factor in establishing a headache diagnosis and
determining the future work-up and treatment plan. An imaging study is not necessary in the vast majority of
patients presenting with headache. Nevertheless, brain imaging is warranted in the patients with danger signs
suggesting a secondary cause of headache. (See 'Indications for imaging studies' below.)
History and examination A thorough history can focus the physical examination and determine the need for
further investigations and neuroimaging studies. A systematic history should include the following:
Age at onset
Presence or absence of aura and prodrome
Frequency, intensity, and duration of attack
Number of headache days per month
Time and mode of onset
Quality, site, and radiation of pain
Associated symptoms and abnormalities
Family history of migraine
Precipitating and relieving factors
Effect of activity on pain
Relationship with food/alcohol
Response to any previous treatment
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Any recent change in vision

Association with recent trauma
Any recent changes in sleep, exercise, weight, or diet
State of general health
Change in work or lifestyle (disability)
Change in method of birth control (women)
Possible association with environmental factors
Effects of menstrual cycle and exogenous hormones (women)
The examination of an adult with headache complaints should cover the following areas:
Obtain blood pressure and pulse
Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles
The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and
otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests. Gait examination should
include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and
Romberg test.
The majority of patients with headache complaints have a completely normal physical and neurologic
examination. However, some types of primary headache may be associated with specific abnormalities:
With tension-type headache, there may be pericranial muscle tenderness.
With migraine, there may be manifestations related to sensitization of primary nociceptors and central
trigeminovascular neurons, such as hyperalgesia and allodynia.
With hemicrania continua or one of the other trigeminal autonomic cephalalgias (cluster headache,
paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks), there may be evidence
of autonomic activation.
Other abnormalities on examination should raise suspicion for a secondary headache disorder. Likewise, danger
signs (ie, red flags) should prompt further evaluation, as discussed in the sections below.
Danger signs Paying attention to danger signs is important since headaches may be the presenting symptom
of a space-occupying mass or vascular lesion, infection, metabolic disturbance, or a systemic problem. The
following features in the history can serve as warning signs of possible serious underlying disease [8-10]. (See
"Evaluation of the adult with headache in the emergency department".)
The mnemonic SNOOP is a reminder of the danger signs ("red flags") for the presence of serious underlying
disorders that can cause acute or subacute headache [11,12]:
Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised
state including HIV)
Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema,
focal neurologic symptoms or signs, meningismus, or seizures)
Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap")
Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache
awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual
activity)
Previous headache history with headache progression or change in attack frequency, severity, or clinical
features
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Any of these findings should prompt further investigation, including brain imaging with MRI or CT. (See
'Indications for imaging studies' below.)
Other features suggesting a secondary headache source Other features that suggest a specific source of
headache pain include the following:
Impaired vision or seeing halos around light suggests the presence of glaucoma. Suspicion for subacute
angle closure glaucoma should be raised by relatively short duration (often less than one hour) unilateral
headaches that do not meet criteria for migraine arising after age 50 [13].
Visual field defects suggest the presence of a lesion of the optic pathway (eg, due to a pituitary mass).
Sudden, severe, unilateral vision loss suggests the presence of optic neuritis.
Blurring of vision on forward bending of the head, headaches upon waking early in the morning that
improve with sitting up, and double vision or loss of coordination and balance should raise the suspicion of
raised intracranial pressure; this should also be considered in patients with chronic, daily, progressively
worsening headaches associated with chronic nausea.
In patients who present with headache that is relieved with recumbency and exacerbated with upright
posture, the diagnosis of headache attributed to spontaneous intracranial hypotension should be
considered. An additional major feature of this headache syndrome is diffuse meningeal enhancement on
brain MRI. The accepted etiology is cerebrospinal fluid (CSF) leakage, which may occur in the context of
rupture of an arachnoid membrane. (See "Headache attributed to spontaneous intracranial hypotension:
Pathophysiology, clinical features, and diagnosis".)
The presence of nausea, vomiting, worsening of headache with changes in body position (particularly
bending over), an abnormal neurologic examination, and/or a significant change in prior headache pattern
suggests the headache was caused by a tumor. (See "Clinical presentation and diagnosis of brain tumors".)
Intermittent headaches with high blood pressure are suggestive of pheochromocytoma. (See "Clinical
presentation and diagnosis of pheochromocytoma".)
Diagnostic instruments As mentioned above, the most common headache syndromes frequently present
with characteristic symptoms (table 1). However, there may be considerable symptom overlap; one
population-based survey found that less than one-half of patients who complained of headaches that met criteria
for migraine were properly diagnosed [14]. Migraine symptoms may also overlap with other causes of headache.
As an example, a significant number of patients with migraine may have nasal symptoms that suggest sinus
disease [15]; in addition, a study of primary care patients with recurrent sinus headache found that 90 percent
experienced attacks that met the International Headache Society (IHS) criteria for migraine [16]. (See 'Sinus
symptoms' below.)
Given these pitfalls, a number of diagnostic instruments have been proposed, mainly to assist with the diagnosis
of migraine, the most common primary headache syndrome in patients presenting to primary care physicians.
One such instrument (ID Migraine) preselects eligible subjects as those who had two or more headaches in the
previous three months and indicated either that they might want to speak with a healthcare professional about
their headaches or that they experienced a headache that limited their ability to work, study, or enjoy life [17].
The screen employs three questions:
During the last three months, did you have the following with your headaches?
You felt nauseated or sick to your stomach
Light bothered you (a lot more than when you don't have headaches)
Your headaches limited your ability to work, study, or do what you needed to do for at least one day
The ID migraine screen is positive if the patient answers yes to two of the three items. In a systematic review of
13 studies that involved over 5800 patients, the pooled sensitivity and specificity of ID migraine was 0.84 and
0.76, respectively [18]. A positive ID migraine increased the pretest probability of migraine from 59 to 84 percent,
whereas a negative ID Migraine score reduced the probability of migraine from 59 to 23 percent.
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Another simple and validated instrument, the brief headache screen, consists of three to six questions [19]. One
version includes the following four questions:
How often do you get severe headaches (ie, without treatment it is difficult to function)?
How often do you get other (milder) headaches?
How often do you take headache relievers or pain pills?
Has there been any recent change in your headaches?
In one study, the presence of episodic disabling headache correctly identified migraine in 136 of 146 patients (93
percent) with episodic migraine, and 154 of 197 patients (78 percent) with chronic headache with migraine, with
a specificity of 63 percent [19]. Only 6 of 343 patients (2 percent) with migraine were not identified by disabling
headache. Thus, virtually any patient with severe episodic headaches can be considered to have migraine.
Questions 2 and 3 can be helpful for identifying patients with medication overuse (eg, patients who use
symptomatic medications more than three days per week and/or who have daily headaches). Question 4 is
particularly helpful for identifying patients who may have an important secondary cause of headache; a patient
with a stable pattern of headache for six months is unlikely to have a serious underlying cause.
Indications for imaging studies Patients with any of the danger signs noted above need urgent brain
imaging (see 'Danger signs' above). Our approach is to perform neuroimaging in the following situations [20]:
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Orbital bruit
Onset of headache after age 40 years
Recent significant change in the pattern, frequency, or severity of headaches
Progressive worsening of headache despite appropriate therapy
MRI is the preferred brain imaging modality for most patients because it is more sensitive than CT scan for
detecting edema, vascular lesions, and other types of intracranial pathology, particularly in the posterior fossa.
However, CT is more widely available and is therefore more useful in urgent or emergency care situations when
there is concern for subarachnoid hemorrhage as the cause of thunderclap headache.
It may also be reasonable to image a patient presenting with nonmigrainous featureless headache, ie, bilateral
nonthrobbing headache without nausea and without sensitivity to light, sound, or smell [21]. Such an approach
would have an estimated yield of 2 percent for detecting a treatable cause.
In the remaining patients, there are no randomized, controlled trials that help delineate when imaging is
necessary, and no such trials are likely to be forthcoming as blinding and randomization would present ethical
problems. As a result, the decision to scan or not to scan in headache is likely to remain one of clinical judgment
[21].
The vast majority of patients without danger signs do not have a secondary cause of headache [22,23]. As an
example, in a study of 373 patients with chronic headache at a tertiary referral center, all had one or more of the
following characteristics that prompted referral for head CT scanning: increased severity of symptoms or
resistance to appropriate drug therapy, change in characteristics or pattern of headache, or family history of an
intracranial structural lesion [24]. Only four scans (1 percent) showed significant lesions (two osteomas, one low
grade glioma, and one aneurysm); only the aneurysm was treated.
Neuroimaging is usually not warranted for patients with migraine and a normal neurologic examination, although
a lower threshold for imaging is reasonable for patients with atypical migraine features or in patients who do not
fulfill the strict definition of migraine [25]. However, brain imaging for no other reason than reassurance is
sometimes performed in clinical practice. In the end, patients are seeking a reason for the problem. It is
important that the clinician provide the patient with a clear explanation of both the diagnosis and the reason for
the brain scan, especially if the decision is made to obtain imaging in someone suspected of having primary
headache [21].
Indications for lumbar puncture Lumbar puncture (LP) for cerebrospinal fluid analysis is urgently indicated
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in patients with headache when there is clinical suspicion of subarachnoid hemorrhage in the setting of a
negative or normal head CT scan. In addition, LP is indicated when there is clinical suspicion of an infectious or
inflammatory etiology of headache. These issues are discussed elsewhere. (See "Clinical manifestations and
diagnosis of aneurysmal subarachnoid hemorrhage", section on 'Diagnosis of subarachnoid hemorrhage' and
"Lumbar puncture: Technique, indications, contraindications, and complications in adults", section on
'Indications'.)
PATIENT SETTINGS Differences in patient demographics, comorbidities, and headache features can guide
the evaluation to help ensure appropriate diagnosis and management.
Emergency The evaluation of the adult presenting to the emergency department with headache is reviewed
in detail elsewhere (see "Evaluation of the adult with headache in the emergency department"). The main goal of
the evaluation is to differentiate the relatively small number of patients with serious or life-threatening headaches
from the majority with benign primary headaches (algorithm 1 and algorithm 2).
Sudden onset Severe headache of sudden onset (ie, that reaches maximal intensity within a few seconds or
less than one minute after the onset of pain) is known as thunderclap headache because its explosive and
unexpected nature is likened to a "clap of thunder." Thunderclap headache requires urgent evaluation as such
headaches may be harbingers of subarachnoid hemorrhage and other potentially ominous etiologies (table 4).
These include cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension,
pituitary apoplexy, retroclival hematoma, ischemic stroke, acute hypertensive crisis with reversible posterior
leukoencephalopathy syndrome, "orgasmic" headache associated with sexual activity, third ventricular colloid
cysts, bacterial and viral meningitis, complicated sinusitis, and reversible cerebral vasoconstriction syndromes.
(See "Thunderclap headache".)
For all patients with thunderclap headache, we recommend head CT and, if head CT is normal, lumbar puncture
with measurement of opening pressure and cerebrospinal fluid analysis to exclude subarachnoid hemorrhage.
For patients with thunderclap headache who have nondiagnostic head CT and lumbar puncture, imaging of the
cerebral circulation is necessary. We suggest obtaining brain MRI and noninvasive neurovascular imaging such
as MR or CT angiography/venography. (See "Thunderclap headache", section on 'Diagnostic evaluation'.)
New or recent onset headache The absence of similar headaches in the past is another finding that
suggests a possible serious disorder.
New headache in patients older than 40 years may suggest underlying pathology
New headache type in a patient with cancer suggests metastasis
New headache type in a patient with Lyme disease suggests meningoencephalitis
New headache type in a patient with HIV suggests an opportunistic infection or tumor
In contrast, patients with migraine usually have had similar types of headaches in the past.
Brain tumor is a rare cause of headache but should be considered in patients presenting with focal neurologic
signs. It should also be considered when new-onset headaches occur in adults older than 50 years. A prior
history of headache does not rule out the possibility of brain tumor, and a change in headache pattern is a
diagnostic "red flag." The features of brain tumor headache are generally nonspecific and vary widely with tumor
location, size, and rate of growth. The headache is usually bilateral, but can be on the side of the tumor. Brain
tumor headache often resembles tension-type headache, but may resemble migraine or a variety of other
headache types. (See "Brain tumor headache".)
Chronic headache Chronic daily headache is not a specific headache type, but a syndrome that
encompasses a number of primary and secondary headaches. The term "chronic" refers either to the frequency
of headaches or to the duration of the disease, depending upon the specific headache type. (See "Overview of
chronic daily headache".)
With headache subtypes of long duration (ie, four hours or more), "chronic" indicates a headache frequency of
15 or more days a month for longer than three months in the absence of organic pathology. These headache
subtypes are:
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Chronic migraine headache (see "Chronic migraine")

Chronic tension-type headache (see "Tension-type headache in adults: Pathophysiology, clinical features,
and diagnosis")
Medication overuse headache, which is typically preceded by an episodic headache disorder (usually
migraine or tension-type headache) that has been treated with frequent and excessive amounts of acute
symptomatic medications (see "Medication overuse headache: Etiology, clinical features, and diagnosis")
Hemicrania continua, a strictly unilateral, continuous headache with superimposed exacerbations of
moderate to severe intensity accompanied by autonomic features and sometimes by migrainous symptoms
(see "Hemicrania continua")
New daily persistent headache, characterized by headache that begins rather abruptly and is daily and
unremitting from onset or within three days of onset at most, typically in individuals without a prior
headache history (see "New daily persistent headache")
With headache subtypes of shorter duration (ie, less than four hours), "chronic" refers to a prolonged duration of
the condition itself without remission. The headache subtypes in this category are the following:
Chronic cluster headache (see "Cluster headache: Epidemiology, clinical features, and diagnosis")
Chronic paroxysmal hemicrania, characterized by unilateral, brief, severe attacks of pain associated with
cranial autonomic features that recur several times per day with individual headache attacks that usually
last 2 to 30 minutes (see "Paroxysmal hemicrania: Clinical features and diagnosis")
Short-lasting unilateral neuralgiform headache attacks, characterized by sudden brief attacks of severe
unilateral head pain in orbital, peri-orbital, or temporal regions, accompanied by ipsilateral cranial
autonomic symptoms (see "Short-lasting unilateral neuralgiform headache attacks: Clinical features and
diagnosis")
Hypnic headache, also known as "alarm clock headache," which occurs almost exclusively after the age of
50 years and is characterized by episodes of dull head pain, often bilateral, that awaken the sufferer from
sleep (see "Hypnic headache")
Primary stabbing headache, characterized by sudden brief attacks of sharp, jabbing head pain in orbital,
peri-orbital, or temporal regions (see "Primary stabbing headache")
Older patients Older patients are at increased risk for secondary types of headache (eg, giant cell arteritis,
trigeminal neuralgia, subdural hematoma, acute herpes zoster and postherpetic neuralgia, and brain tumors) and
some types of primary headache (hypnic headache, cough headache, and migraine accompaniments) [26].
Giant cell (temporal) arteritis is a chronic vasculitis of large and medium sized vessels. The greatest risk
factor for developing giant cell arteritis is aging. The disease seldom occurs before age 50 years, and its
incidence rises steadily thereafter. A new type of headache occurs in two-thirds of affected individuals. The
head pain tends to be located over the temporal areas but can be frontal or occipital in location. The
headaches may be mild or severe. Other common symptoms include fever, fatigue, weight loss, jaw
claudication, visual symptoms, particularly transient monocular visual loss and diplopia, and symptoms of
polymyalgia rheumatica. (See "Clinical manifestations of giant cell (temporal) arteritis".)
Trigeminal neuralgia is defined clinically by sudden, usually unilateral, severe, brief, stabbing or lancinating,
recurrent episodes of pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve.
The incidence increases gradually with age; most idiopathic cases begin after age 50 years. (See
"Trigeminal neuralgia".)
Chronic subdural hematoma may present with the insidious onset of headaches, light-headedness,
cognitive impairment, apathy, somnolence, and occasionally seizures. (See "Subdural hematoma in adults:
Etiology, clinical features, and diagnosis".)
Acute herpes zoster and postherpetic neuralgia often involve cervical and trigeminal nerves. Pain is the
most common symptom of zoster and approximately 75 percent of patients have prodromal pain in the
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dermatome where the rash subsequently appears. The major risk factors for postherpetic neuralgia are
older age, greater acute pain, and greater rash severity. (See "Clinical manifestations of varicella-zoster
virus infection: Herpes zoster" and "Postherpetic neuralgia".)
Brain tumor should be considered as a possible cause of new-onset headaches in adults over age 50
years, as discussed above. (See 'New or recent onset headache' above and "Brain tumor headache".)
Hypnic headache, also known as "alarm clock headache," occurs almost exclusively after the age of 50
years and is characterized by episodes of dull head pain, often bilateral, that awaken the sufferer from
sleep. (See "Hypnic headache".)
Primary cough headache most often affects people older than age 40 years and is provoked by coughing or
straining in the absence of any intracranial disorder. (See "Primary cough headache".)
Late-life migraine accompaniments are symptoms related to the onset after the age of 40 years of migraine
aura without headache [27]. The most common symptoms are visual auras, followed by sensory auras
(paresthesia), speech disturbances, and motor auras (weakness or paralysis). The most common
presentation is gradual evolution of aura symptoms with spread of transient neurologic deficits over several
minutes and serial progression from one symptom to another.
Pregnancy New headache or change in headache during pregnancy may be due to migraine or tension-type
headaches, but many other conditions can present with headache at this time, particularly pre-eclampsia,
post-dural puncture headache, and cerebral venous thrombosis. Among pregnant women with the onset of new
or atypical headache, approximately one-third have migraine, one-third have pre-eclampsia/eclampsia-related
headache, and the remaining one-third have a variety of other causes of headache.
Pre-eclampsia must be ruled in or out in every pregnant woman over 20 weeks of gestation with headache. (See
"Headache in pregnant and postpartum women".)
Fever Fever associated with headache may be caused by intracranial, systemic, or local infection, as well as
other etiologies (table 5).
Immunocompromised New headache type in a patient with HIV or other immunocompromised state
suggests an opportunistic infection or neoplasm as the cause.
Traumatic brain injury Headache is variably estimated as occurring in 25 to 78 percent of persons following
mild traumatic brain injury. Paradoxically, headache prevalence, duration, and severity is greater in those with
mild head injury compared with those with more severe trauma. Most often, headache following head trauma can
be classified similarly to nontraumatic headaches; migraine and tension-type headache predominate. (See
"Postconcussion syndrome", section on 'Headaches'.)
Sinus symptoms Although sinus headache is commonly diagnosed by physicians and self-diagnosed by
patients, acute or chronic sinusitis appears to be an uncommon cause of recurrent headaches [2-4].
Autonomic features characteristically occur in trigeminal autonomic cephalgias such as cluster headaches and
are also common with migraine headache. These symptoms may include nasal congestion, rhinorrhea, tearing,
color and temperature change, and changes in pupil size. (See "Pathophysiology, clinical manifestations, and
diagnosis of migraine in adults".)
The prominence of sinus symptoms often leads to the misdiagnosis of "sinus headache" in patients who meet
diagnostic criteria for migraine or, less often, tension-type headache. This point is illustrated by an observational
study that enrolled 2991 patients with a history of physician- or self-diagnosed sinus headache and no previous
history of migraine; 88 percent of these patients fulfilled criteria for migraine or migrainous headache, and 8
percent fulfilled criteria for tension-type headache [28]. In the patients with migraine or migrainous headache,
sinus pain, pressure, and congestion commonly occurred in association with typical migraine features such as
pulsing head pain and sensitivity to activity, light, and sound (figure 1).
Pain related purely to sinus conditions may have some features that aid in distinguishing it from migraine [29,30].
Sinus-related pain or headache is typically described as a pressure-like or dull sensation that is usually bilateral
and periorbital. However, it can be unilateral with deviated septum, middle or inferior turbinate hypertrophy, or
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unilateral sinus disease. In addition, sinus-related pain is typically associated with nasal obstruction or
congestion, lasts for days at a time, and is usually not associated with nausea, vomiting, photophobia, or
sonophobia. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)
The severity, extent, and location of sinus-related pain do not correlate with the extent or location of mucosal
disease as revealed by imaging [30].
In general, the following principles apply to the relationship of rhinosinusitis and headache [29,31,32]:
A stable pattern of recurrent headaches that interfere with daily function is most likely migraine.
Recurrent self-limited headaches associated with rhinogenic symptoms are most likely migraine.
Prominent rhinogenic symptoms with headache as one of several symptoms should be evaluated carefully
for otolaryngologic conditions.
Headache associated with fever and purulent nasal discharge is likely rhinogenic in origin.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
Basics topics (see "Patient information: Headache (The Basics)")
Beyond the Basics topics (see "Patient information: Headache causes and diagnosis in adults (Beyond the
Basics)" and "Patient information: Headache treatment in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
While episodic tension-type headache is the most frequent headache type in population-based studies,
migraine is the most common diagnosis in patients presenting to primary care physicians with headache.
Clinicians can easily become familiar with the most common primary headache disorders and how to
distinguish them (table 1). (See 'Epidemiology and classification' above.)
Using the patient history as the primary diagnostic tool, the initial headache evaluation should determine
whether there is a potentially dangerous secondary cause of headache or whether the headache is due to
one of the common types of primary headache. (See 'Evaluation' above.)
The mnemonic SNOOP is a reminder of the danger signs ("red flags") for the presence of serious
underlying disorders that can cause acute or subacute headache:
Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy,
immunocompromised state including HIV)
Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness,
papilledema, focal neurologic symptoms or signs, meningismus, or seizures)
Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap")
Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache
awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or
sexual activity)
Previous headache history with headache progression or change in attack frequency, severity, or
clinical features
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Any of these findings should prompt further investigation, including brain imaging with MRI or CT. (See
'Danger signs' above and 'Indications for imaging studies' above.)
Differences in patient demographics, comorbidities, and headache features can guide the evaluation to
help ensure appropriate diagnosis and management. (See 'Patient settings' above.)
Thunderclap headache may be the harbinger of subarachnoid hemorrhage and other potentially
ominous etiologies (table 4) (see 'Sudden onset' above)
The absence of similar headaches in the past is another finding that suggests a possible serious
disorder (see 'New or recent onset headache' above)
Chronic daily headache is a syndrome that encompasses a number of primary and secondary
headaches (see 'Chronic headache' above)
Older patients are at increased risk for secondary types of headache (eg, giant cell arteritis, trigeminal
neuralgia, subdural hematoma, acute herpes zoster and postherpetic neuralgia, and brain tumors)
and some types of primary headache (hypnic headache, cough headache, and migraine
accompaniments) (see 'Older patients' above)
Pre-eclampsia must be ruled in or out in every pregnant woman over 20 weeks of gestation with
headache (see 'Pregnancy' above)
Fever associated with headache may be caused by intracranial, systemic, or local infection, as well as
other etiologies (table 5) (see 'Fever' above)
Headache is a frequent sequelae of mild traumatic brain injury (see 'Traumatic brain injury' above)
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6. Buring JE, Hebert P, Romero J, et al. Migraine and subsequent risk of stroke in the Physicians' Health
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adults in Norway. J Neurol Neurosurg Psychiatry 2002; 72:463.
8. Edmeads J. Emergency management of headache. Headache 1988; 28:675.
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10. Lynch KM, Brett F. Headaches that kill: a retrospective study of incidence, etiology and clinical features in
cases of sudden death. Cephalalgia 2012; 32:972.
11. Dodick D. Headache as a symptom of ominous disease. What are the warning signals? Postgrad Med
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12. Venkatesan A. Case 13: a man with progressive headache and confusion. MedGenMed 2006; 8:19.
13. Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR. Intermittent headaches as the presenting sign of
subacute angle-closure glaucoma. Neurology 2005; 65:757.
14. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American
Migraine Study II. Headache 2001; 41:638.
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15. Barbanti P, Fabbrini G, Pesare M, et al. Unilateral cranial autonomic symptoms in migraine. Cephalalgia
2002; 22:256.
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17. Rapoport AM, Bigal ME. ID-migraine. Neurol Sci 2004; 25 Suppl 3:S258.
18. Cousins G, Hijazze S, Van de Laar FA, Fahey T. Diagnostic accuracy of the ID Migraine: a systematic
review and meta-analysis. Headache 2011; 51:1140.
19. Maizels M, Burchette R. Rapid and sensitive paradigm for screening patients with headache in primary
care settings. Headache 2003; 43:441.
20. Kumar KL, Cooney TG. Headaches. Med Clin North Am 1995; 79:261.
21. Goadsby PJ. To scan or not to scan in headache. BMJ 2004; 329:469.
22. Tsushima Y, Endo K. MR imaging in the evaluation of chronic or recurrent headache. Radiology 2005;
235:575.
23. You JJ, Gladstone J, Symons S, et al. Patterns of care and outcomes after computed tomography scans
for headache. Am J Med 2011; 124:58.
24. Dumas MD, Pexman JH, Kreeft JH. Computed tomography evaluation of patients with chronic headache.
CMAJ 1994; 151:1447.
25. Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache.
Neurology 2000; 54:1553.
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classic presentations and new considerations in diagnosis and management. Med Clin North Am 2014;
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27. Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A
narrative review. Cephalalgia 2014.
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self-reported or physician-diagnosed "sinus" headache. Arch Intern Med 2004; 164:1769.
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30. Tarabichi M. Characteristics of sinus-related pain. Otolaryngol Head Neck Surg 2000; 122:842.
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Topic 3349 Version 16.0
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GRAPHICS
Characteristics of migraine, tension-type, and cluster headache
syndromes
Symptom
Location
Migraine
Unilateral in 60 to 70
percent; bifrontal or global
Tension-type
Bilateral
in 30 percent
Characteristics
Cluster
Always unilateral, usually
begins around the eye or
temple
Gradual in onset,
Pressure or
Pain begins quickly, reaches
crescendo pattern;
pulsating; moderate or
tightness which
waxes and wanes
a crescendo within minutes;

pain is deep, continuous,
severe intensity;
aggravated by routine
excruciating, and explosive

in quality
physical activity
Patient
Patient prefers to rest in a
Patient may remain
appearance
dark, quiet room
active or may need

to rest
Patient remains active
Duration
4 to 72 hours
Variable
30 minutes to 3 hours
Associated
symptoms
Nausea, vomiting,
photophobia,
None
Ipsilateral lacrimation and

redness of the eye; stuffy
phonophobia; may have

aura (usually visual, but
nose; rhinorrhea; pallor;

sweating; Horner's
can involve other senses

or cause speech or motor
syndrome; focal neurologic

symptoms rare; sensitivity
deficits)
to alcohol
Graphic 68064 Version 4.0
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Headache triggers
Diet
Stress
Alcohol
Let-down periods
Chocolate
Times of intense activity
Aged cheeses
Loss or change (death, separation, divorce,

job change)
Monosodium glutamate
Aspartame
Caffeine
Nuts
Nitrites, nitrates
Hormones
Menses
Ovulation
Hormone replacement (progesterone)
Sensory stimuli
Moving
Crisis
Changes of environment or habits

Weather
Travel (crossing time zones)
Seasons
Altitude
Schedule changes
Sleeping patterns
Dieting
Strong light
Flickering lights
Skipping meals
Irregular physical activity
Odors
Sounds, noise
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Clinical features of the trigeminal autonomic cephalalgias
Sex
(female:male)
Cluster
Paroxysmal
SUNCT and
Hemicrania
headache
hemicrania
SUNA
continua
1:3 to 1:7
1:1 to 2.7:1
1:1.5
2:1
Stabbing, boring
Sharp, stabbing,
Burning,
Throbbing, sharp,
throbbing
stabbing, sharp
pressure, dull,
burning, aching,
Pain
Type
or stabbing
Severity
Excruciating
Excruciating
Severe to
Mild to severe
excruciating
Site
Orbit, temple
Orbit, temple
Periorbital
Orbital, frontal,
temporal; less
often occipital
Attack
1 every other day
1 to 40 a day
frequency
to 8 per day
(>5 per day for

more than half
1 to 200 per day
Continuous pain
with
exacerbations
the time)
Duration of
15 to 180
attack
minutes
Autonomic
Yes
2 to 30 minutes
1 to 600 seconds
Months to years
Yes
Yes (prominent
Yes
features
conjunctival
injection and
lacrimation with
SUNCT)
Restlessness
Yes
Yes
Frequent
Yes
Yes
Yes
Rare
Frequent
Alcohol trigger
Yes
Occasional
No
Occasional
Cutaneous
No
Rare
Yes
No
None
Absolute
None
Absolute
Abortive
Sumatriptan
Nil
Lidocaine
Nil
treatment
injection or nasal
spray
and/or
agitation
Migrainous
features
(nausea,
photophobia, or
phonophobia)
triggers
Indomethacin
effect
intravenous
infusion
Oxygen
Prophylactic
Verapamil
treatment
Indomethacin
Lamotrigine
Methysergide
Topiramate
Lithium
Gabapentin
Indomethacin
SUNCT: short-lasting unilateral neuralgiform pain with conjunctival injection and tearing; SUNA: short-
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lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms.

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Management of headache in the emergency department-I
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Management of headache in the emergency

department-II
CNS: central nervous system; CSF: cerebrospinal fluid; CT: computed tomography
scan; LP: lumbar puncture; RBC: red blood cell; WBC: white blood cell.
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Etiologies of thunderclap headache

Subarachnoid hemorrhage
Sentinel headache
Reversible cerebral vasoconstriction syndromes
Cerebral venous thrombosis
Cervical artery dissection
Spontaneous intracranial hypotension
Pituitary apoplexy
Orgasmic headache associated with sexual activity
Retroclival hematoma
Ischemic stroke
Acute hypertensive crisis
Colloid cyst of the third ventricle
Infections (eg, acute complicated sinusitis)
Primary thunderclap headache
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Differential diagnosis of headache with fever

Intracranial infection
Meningitis
Bacterial
Fungal
Viral
Lymphocytic
Encephalitis
Brain abscess
Subdural empyema
Systemic infection
Bacterial infection
Viral infection
HIV/AIDS
Other systemic infection
Other causes
Familial hemiplegic migraine
Pituitary apoplexy
Rhinosinusitis
Subarachnoid hemorrhage
Malignancy of central nervous system
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Sinus symptoms are common in patients with

migraine
In this observational study of patients with a history of sinus headache

and no previous history of migraine, sinus pain, pressure, and
congestion commonly occurred in association with typical migraine
features such as pulsing head pain and sensitivity to activity, light, and
sound.
Reproduced with permission from: Schreiber CP, Hutchinson S, Webster CJ,
et al. Prevalence of migraine in patients with a history of self-reported or
physician-diagnosed "sinus" headache. Arch Intern Med 2004; 164:1769.
Copyright 2004 American Medical Association. All rights reserved.
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Disclosures
Disclosures: Zahid H Bajwa, MD Consultant/Advisory Boards: Allergan (migraine [onabotulinumtoxinA]); Depomed [Migraine, pain
(Diclofenac potassium)]; Kaleo [Opioid toxicity (Naloxone)]. Speaker's Bureau: Depomed [Migraine, pain (Diclofenac potassium)]. R
Joshua Wootton, MDiv, PhD Nothing to disclose. Jerry W Swanson, MD Nothing to disclose. John F Dashe, MD, PhD Nothing to
disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
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