Assessment of acute headache in adults

Detailed history provides the most useful information in evaluating acute headache. Aspects to focus on include the temporal profile, precipitating factors, associated symptoms, and medical and family history. The following are the most common diagnostic clues, although not all headaches present with typical symptoms.

Temporal features

Sudden onset

• Subarachnoid haemorrhage, stroke, venous sinus thrombosis, meningitis, hypertensive encephalopathy, pituitary apoplexy, acute angle-closure glaucoma[3]Chinthapalli K, Logan AM, Raj R, et al. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond). 2018 Oct;18(5):422-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334100 http://www.ncbi.nlm.nih.gov/pubmed/30287441?tool=bestpractice.com [4]Devenney E, Neale H, Forbes RB. A systematic review of causes of sudden and severe headache (thunderclap headache): should lists be evidence based? J Headache Pain. 2014 Aug 14;15(1):49. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/1129-2377-15-49 http://www.ncbi.nlm.nih.gov/pubmed/25123846?tool=bestpractice.com [5]Flores-Sánchez BC, Tatham AJ. Acute angle closure glaucoma. Br J Hosp Med (Lond). 2019 Dec 2;80(12):C174-9. http://www.ncbi.nlm.nih.gov/pubmed/31822188?tool=bestpractice.com [6]Renton BJ, Bastawrous A. Acute angle closure glaucoma (AACG): an important differential diagnosis for acute severe headache. Acute Med. 2011;10(2):77-8. http://www.ncbi.nlm.nih.gov/pubmed/22041605?tool=bestpractice.com

• Sudden-or abrupt-onset severe ('thunderclap') headache is a predictor of significant pathology (sensitivity 65%, specificity 62%)[7]Locker TE, Thompson C, Rylance J, et al. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache. 2006 Jun;46(6):954-61. http://www.ncbi.nlm.nih.gov/pubmed/16732841?tool=bestpractice.com

Duration of hours to days

• Tension headache, migraine

Episodic, 2 to 10 episodes per day, lasting seconds to minutes

• Cluster headache

• Trigeminal neuralgia

Awaken from sleep/morning headache

• Intracranial mass

• Obstructive sleep apnoea[8]KoÇ G, Metİn KM, AkÇay BD, et al. Relationship between apnea-hypopnea index and oxygen desaturation in REM-sleep period and morning headache in patients with obstructive sleep apnea syndrome. Noro Psikiyatr Ars. 2020 Dec;57(4):294-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735150 http://www.ncbi.nlm.nih.gov/pubmed/33354121?tool=bestpractice.com

Aligned with menstrual cycle

• Menstrual headache

Precipitating factors

Trauma

• Subdural haematoma, subarachnoid haemorrhage, epidural haematoma, concussive syndrome

Increasing severity and frequency

• Mass lesion, subdural haematoma

Recent high-altitude changes

• Hypoxia/acute mountain sickness

Fatigue or stress

• Tension headache

Valsalva (coughing, sneezing, bending, or exertion)

• Intracranial lesion (posterior fossa)

Aligned with menstrual cycle

• Menstrual headache

Medication changes/withdrawal (caffeine, opiates, pseudoephedrine)

Associated symptoms

Fever

• Systemic infection: meningitis, encephalitis, brain abscess, otitis media

Vomiting

• Mass lesion, brain abscess, migraine, carbon monoxide poisoning

Seizure

• Mass lesion, stroke, meningitis, encephalitis, metabolic, toxic

Dizziness

• Ischaemic or haemorrhagic infarct (posterior fossa), migraine

Warning signs: visual, auditory, gustatory disturbance

• Migraine with aura

Neck pain

• Meningitis, subarachnoid haemorrhage, tension headache, musculoskeletal pain (cervical paraspinal muscle pain)

Facial pain

• Temporal area: temporomandibular disorders, giant cell arteritis, trigeminal neuralgia

• Eye area: glaucoma

• Ear area: otitis media

• Sinusitis

Visual disturbance

• Migraine, acute angle-closure glaucoma

Lacrimation, rhinorrhoea

• Cluster headache

• Sinus headache

Medical history

HIV/AIDS or immunocompromised

• Meningitis, encephalitis

Age >50 years with new-onset headache

• Mass lesion, giant cell arteritis

COPD

• Hypoxia

Connective tissue disorders (e.g., systemic lupus erythematosus)

• Cerebral vasculitis

Cancer

• Brain metastases

Hypertension

• Hypertensive headache

Family history of migraines