Approach

While the clues may be subtle, the diagnostic approach to a patient with a headache depends upon crucial features in the history and physical examination.

History of present illness

Is this the worst headache of their life?

  • Yes: consider subarachnoid hemorrhage (SAH).

Is this a "typical" headache?

  • Yes: manage with analgesic medication, rest, hydration.

Did the patient's "typical" headache improve after conventional treatment?

  • Yes: follow up with headache specialist.

  • No: consider other diagnosis.

  • Maybe: consider other causes (e.g., SAH, venous sinus thrombosis, meningitis).

When did the headache begin?

  • Sudden-onset, unprovoked: SAH (11% to 25% of sudden-onset headaches are due to SAH), stroke, venous sinus thrombosis, meningitis, hypertensive encephalopathy, pituitary apoplexy, acute angle-closure glaucoma[3][4][5][6]

  • Sudden-onset, provoked by exertion, orgasm, cough, sneeze: benign transient intracranial pressure increase, SAH

  • Subacute, progressive over weeks to months: intracranial lesion (i.e., tumor/mass), subdural hematoma, hydrocephalus

Is the patient older than 50 years, with their first headache?

  • Immediate considerations: giant cell arteritis

What are the exacerbating factors?

  • Erect position: mass lesions

  • Exertion or Valsalva: mass lesions[20]

  • Foods: caffeine, monosodium glutamate

What does the patient do during the headache?

  • Unable to function normally is characteristic of migraine.

  • Able to continue usual activities suggests tension headache.​

What medication has been used?

  • Consider medication overuse headache if a patient is taking:[21][22][23]

    • simple analgesia (e.g., acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]) on ≥15 days per month or

    • opioid, ergot, triptan, or combination analgesia on ≥10 days per month.​

Review of symptoms

Does the patient have a fever?

  • Immediate considerations: meningitis, encephalitis, brain abscess

  • Other considerations: viral syndrome, dehydration

Did the patient vomit?

  • Immediate considerations: meningitis, stroke, SAH, subdural hematoma, epidural hematoma, mass lesions

  • Other considerations: migraine, carbon monoxide poisoning, idiopathic intracranial hypertension

Does the patient have visual complaints?

  • Visual disturbance: stroke, meningitis, migraine, acute angle-closure glaucoma, giant cell arteritis, idiopathic intracranial hypertension, venous sinus thrombosis

  • Photophobia: meningitis, migraine

Did the patient have a seizure?

  • Immediate considerations: mass lesion, meningitis, encephalitis, stroke, toxic or metabolic causes

  • Other considerations: migraine

Does the patient have confusion or altered mental status?

  • Immediate considerations: SAH, stroke, meningitis, encephalitis

Does the patient have dizziness?

  • Immediate considerations: stroke

  • Other considerations: migraine, carbon monoxide poisoning, idiopathic intracranial hypertension

Does the patient have weakness or focal neurologic deficits?

  • Immediate considerations: stroke, SAH

  • Other considerations: migraine with aura

Does the patient have neck pain?

  • Immediate considerations: meningitis, SAH

  • Other considerations: tension headache, musculoskeletal pain (paraspinal muscle strain/tension)

Is there recent head trauma?

  • Immediate considerations: subdural hematoma, SAH, epidural hematoma

  • Urgent considerations: concussion

Is there a history of recent travel?

  • Immediate considerations: meningitis

  • Urgent considerations: Lyme disease, chikungunya, “airplane headache”, Zika virus infection, dengue fever

Is there recent infection in head or neck area?

  • Immediate considerations: brain abscess

Does the patient have facial pain or tenderness?

  • Immediate considerations: giant cell arteritis

  • Other considerations: acute sinusitis, temporomandibular disorders, trigeminal myalgia, dental pain

Does the patient have eye pain?

  • Immediate considerations: acute angle-closure glaucoma

  • Other considerations: sinusitis (also with nasal congestion, pain that increases with head position, facial fullness, sinus tenderness)

Is the patient pregnant or recently postpartum?

  • Consider preeclampsia or eclampsia.

Is the patient female?

  • Premenstrual, perimenopausal, hormonal contraception.

Does the patient have COPD or history of chronic cigarette smoking?

  • Consider hypoxia or hypercapnia.

Are other family members or companion animals sick?

  • Consider carbon monoxide poisoning.

Past medical history

Is the patient immunocompromised?

  • Consider meningitis, encephalitis, brain abscess, lymphoma, toxoplasmosis.

Was their medication changed recently?

  • Consider drug-related headache, withdrawal from caffeine or other stimulants.

Does the patient have a history of cancer?

  • Consider metastatic brain tumor.

Does the patient have hypertension?

  • Urgent considerations: hypertensive urgency

What is the patient's family history?

  • Consider migraine

  • Consider brain tumor (primary cancer or brain metastasis)

Physical examination

The majority of patients with a headache have a normal physical examination. There are a few clues and important aspects of the physical examination that require close attention.

Vital signs and vital considerations

  • Elevated BP: consider hypertensive emergency, hypertensive urgency

  • Temperature: consider infectious source

  • If increased intracranial pressure, may see Cushing response (hypertension, bradycardia, and bradypnea)

Head, eyes, ears, nose, and throat

  • Listening for bruit at neck, eyes, and head: atrioventricular malformation

  • Palpation of head and neck for tenderness: paraspinal muscle tenderness/tension headache

  • Tenderness over frontal and/or maxillary sinuses: consider sinusitis

  • Tenderness over temporomandibular joint (TMJ): TMJ dysfunction

  • Neck stiffness/meningismus: meningitis

  • Palpation of temporal artery for tenderness: giant cell arteritis

  • Fundoscopy and Snellen chart: papilledema (causes of elevated intracranial pressure)

  • Dental examination: caries/wisdom tooth impaction

  • Ear examination: otitis media

Focused physical examination

  • Extracranial structures evaluation such as carotid arteries, sinuses, scalp arteries, cervical paraspinal muscles.

  • Examination of the neck in flexion versus lateral rotation for meningeal irritation. Even a subtle limitation of neck flexion may be considered an abnormality.

Focused neurologic examination

May be capable of detecting most of the abnormal signs likely to occur in patients with headache due to acquired disease or a secondary headache. This examination should include at least the following evaluations:

  • Assessment of orientation, consciousness (Glasgow coma scale), presence of confusion, and memory impairment

  • Ophthalmologic examination: pupillary symmetry and reactivity, optic fundi, visual fields, and ocular motility

  • Cranial nerve examination: corneal reflexes, facial sensation, and facial symmetry

  • Symmetric muscle tone, strength (may be as subtle as arm or leg drift), or deep tendon reflexes

  • Sensation

  • Plantar response(s): gait, arm, and leg coordination

  • Abnormal plantar reflex (Babinski sign): positive in central nervous system lesions

  • Painful knee extension with hip flexed (Kernig sign); 5% positive in meningism

  • Hip flexion with neck flexion (Brudzinski sign): 5% positive in meningism

Investigations

Noncontrast computed tomography (CT) brain[13]

  • Consider if the patient has:

    • Sudden-onset severe headache that reaches maximal severity within one hour

    • Headache with ≥1 of the following red flags: increasing frequency or severity, fever or neurologic deficit, history of cancer or immunocompromise, older age (>50 years) of onset, or post-traumatic onset

    • Headache with new onset or pattern during pregnancy or peripartum period

    • Headache with features of intracranial hypertension (e.g., papilleodema, pulsatile tinnitus, visual symptoms worse on Valsalva)

Magnetic resonance imaging (MRI) brain[13][24]

  • Consider if the patient has:

    • Headache with features of intracranial hypertension (e.g., papilloedema, pulsatile tinnitus, visual symptoms worse on Valsalva)

    • Headache with features of intracranial hypotension (e.g., positional, worse when upright, better when lying down)

    • Headache with new onset or pattern during pregnancy or peripartum period

    • Headache with ≥1 of the following red flags: increasing frequency or severity, fever or neurologic deficit, history of cancer or immunocompromise, older age (>50 years) of onset, or post-traumatic onset

    • New primary headache of suspected trigeminal autonomic origin

Secondary headache disorders are less common than primary headache disorders.[25]​ Using International Classification of Headache Disorders 3 criteria may help to differentiate primary from secondary headache, with a concomitant reduction in neuroimaging studies (CT and/or MRI) conducted to detect uncommon secondary causes and/or to relieve patient anxiety.​[26][27]

Lumbar puncture (LP)

  • Order an LP after a negative CT without contrast:

    • If the patient has the worst headache of their life, or a "thunder-clap headache" (SAH)[16]

    • If the patient has a fever (brain abscess, meningitis, encephalitis)

    • If the patient has neck stiffness (SAH, meningitis)

    • If the patient is young, overweight, and female (sinus venous thrombosis, idiopathic intracranial hypertension)[27]

      Diagnostic lumbar puncture in adults: animated demonstration
      Diagnostic lumbar puncture in adults: animated demonstration

      How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.

Laboratory tests

  • Perform erythrocyte sedimentation rate if the patient is older than 50 years with first headache, blurred vision, facial tenderness (giant cell arteritis).

  • Perform ABG and carboxyhemoglobin if there is a history of smoke inhalation, recently deceased companion animals, old house/furnace, and/or sick household (hypoxia, hypercarbia, carbon monoxide poisoning).

  • A pulse CO-oximeter may reveal elevated CO levels.

  • CBC and liver function tests are performed if preeclampsia is suspected. Urinalysis is also required in these patients.

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