01. Coronary Artery Disease



✔ Most headache dx based on history so good history is key

✔ Determine if headache is new or old, primary or secondary

✔ Very few patients need labs or imaging. Look for red flags to identify high-risk individuals

✔ Avoid opioids when treating as they give only short-term relief and lead to overuse

Resident Editor: Amanda Wright, MD, Janet Chu, MD

Faculty Editor: Morris Levin, MD


  • History:
    • Determine if new or old headache
    • Determine if primary (e.g., tension, migraine, cluster) or secondary (e.g., those caused by infection or vascular disease)
    • Focus on onset, duration, quality, frequency, associated symptoms (n/v, neurological symptoms, aura, photo/phonophobia, weight loss, fevers), alleviating and aggravating factors (activity, food, alcohol), treatments tried, medications (NSAID, opioids, OCP) illicit drug use, family history of headaches and migraines
    • Chronic headaches tend to be primary with low risk for emergency
  • Physical Exam
    • Vital signs: fever, hypertension
    • HEENT: temporal pain to palpation, papilledema, pupillary constriction, visual fields, signs of meningismus, sinus tenderness, dental assessment
    • Neuro: evaluate for any focal neurological deficit, mental status changes
    • Skin: Rashes to suggest meningococcal meningitis
  • Red Flags (use the mnemonic SNOOP)
    • Systemic symptoms: fevers, chills, weight loss, cancer, immunocompromised state (including HIV)
    • Neurologic signs/symptoms: papilledema, confusion, change in mental status, focal neuro exam findings, meningismus, or seizures)
    • Onset: New (especially if age >50), acute, sudden, split second ‘thunderclap’ (reaching max intensity in < 1 min)
    • Other associated conditions or features (e.g., head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, worse with Valsalva maneuvers, or precipitated by cough, exertion, or sexual activity)
    • Previous headache history: first HA or different (change in frequency, severity or features) or progression
  • Labs/Tests: often not indicated; consider ESR/CRP if temporal arteritis considered, LP as needed based on history
  • Radiologic Studies: often not indicated. If red flags, consider CT vs MRI. MRI will have incidental findings in 1 of 10 patients.

Differential Diagnosis: 2 categories: Primary and Secondary

  • Primary headaches
    • Tension: considered most common (though many will be migraine without the usual accompaniments). At least 2 of the following:  Bilateral location, pressing or tightening (non-pulsating) quality, mild to moderate intensity, lack of aggravation by routine physical activity.  Should have normal neuro exam.  Should have no N/V or photophobia&phonophobia.
    • Migraine: At least 2 of the following: unilateral, pulsating, moderate or severe pain intensity, aggravated by routine physical activity; +N/V or photophobia/phonophobia; +/- aura (5-60min, usually visual or sensory sx’s) familial pattern often exists. For diagnosis, consider POUND mnemonic (Pulsatile, One-day (or up to 72h), Unilateral, Nausea or vomiting), Disabling intensity) – 4/5 sx’s = 92% probability, 3/5 = 64% probability.
    • Cluster and other Trigeminal Autonomic Cephalgias (TACs)
      • Cluster HA: episodic (6-12wks/yr), short-lasting (usually 30-60 min for cluster), excruciating unilateral/orbital/supraorbital pain, usually accompanied by at least one of the following ipsilateral autonomic symptoms:  lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead/facial sweating, miosis or ptosis, restlessness or agitation, conjunctival injection. Occurs in men more often than women.  In women, cluster headache features can be less prominent.
      • Paroxysmal hemicrania: 3 main features – many attacks daily (>5/day), and very short-lasting (2-30min), severe and strictly unilateral orbital, supraorbital or temporal pain; symptoms of parasympathetic activation on same side of pain. Responds to indomethacin.
  • Secondary Headaches
  • Associated with Infection
    • Dental caries/abscess – dental, jaw or maxillary region pain
    • Sinusitis – frontal or retro-orbital pain with symptoms of sinusitis, worse with bending forward
    • Meningitis – fever and stiff neck unless chronic from TB, fungus, cancer
    • Encephalitis – fever, mental status changes, seizures
    • Intracranial abscess – fever, focal neurological signs
  • Associated with intracranial mass lesion/bleed:
    • Tumors – subacute, progressive, unilateral pain, may be worse in early morning and or supine; occasionally associated with nausea, vomiting, and focal neurological exam
    • Epidural hematoma – usually secondary to severe head trauma; lucid period followed by loss of consciousness progressing to coma
    • Subdural hematoma – may result from minor head trauma, most common in elderly and patients with substance abuse histories; patients may present with fluctuating level of consciousness.
    • Subarachnoid hemorrhage – classically reported as sudden onset of severe HA, associated with stiff neck, nausea, vomiting, syncope, sometimes focal neurological exam
    • Cerebral venous thrombosis – sometimes related to estrogen (OCP, pregnant), HA can range from acute to chronic. Diagnose with MRI with venography
  • Associated with other diseases:
    • TMJ disease – pain evoked by talking, chewing, or lateral jaw movement; exam reveals tenderness of the joint
    • Temporal arteritis – unilateral, with visual abnormalities, temporal artery tenderness, malaise, fever, jaw claudication, high ESR (though any/all of these may be absent). Consider in all patients with new headache at age >50.  15% of cases associated with PMR.
    • Acute angle closure glaucoma –painful red eye, pupil mid-dilated and fixed, associated with periorbital headache, visual disturbance such as halos, nausea and vomiting.
    • Cerebrovascular ischemia – occasionally prior to or during stroke or TIA, more likely with posterior circulation involvement.
    • Carotid (or vertebral artery) dissection – severe HA, possibly without neck pain, with Horner’s (carotid) and associated TIA/stroke symptoms.
    • Idiopathic intracranial hypertension (pseudotumor cerebri): almost always with papilledema; occurs in young obese women.
    • Hydrocephalus – papilledema, ataxia
    • Intracranial hypotension – HA much worse with sitting or standing, relived in supine, MRI findings of cerebellar tonsillar descent and pachymeningeal enhancement may help to dx.
    • Pheochromocytoma – headache with generalized sweating, tachycardia, and/or sustained or paroxysmal hypertension
    • Malignant hypertension
    • Cervicogenic headache – generally in elderly with structural cervical spine disease, worse with provocation (ROM maneuvers)
  • Associated with drugs:
    • Medication-overuse headache: associated with frequent use of  analgesics, opioids, ergotamine (>2x/wk); Clues are lack of response to acute and proph meds. Risk from highest to lowest: opioids, butalbital-containing combination analgesics, ASA/acetaminophen/caffeine combinations, triptans, NSAIDs
    • Drug-induced headache – nitrates, hormonal supplements, digoxin, caffeine, ethanol, illicit drugs (cocaine, methamphetamines)

Treatment of Primary Headaches

  • Tension
    • Mild analgesics (acetaminophen, NSAIDs, ASA), avoidance of precipitating factors, relaxation techniques. Consider combination of caffeine with acetaminophen, NSAIDs
    • For chronic tension headaches (often actually migraine), consider prophylactic agents – amitriptyline 10mg-75mg at bedtime; SSRIs generally minimally helpful.
  • Cluster/TAC
    • Abortive therapy: 100% oxygen, sumatriptan via injection, intranasal lidocaine
    • Prophylactic therapy:  verapamil, lithium, valproate; and prednisone (which can be used at the start of a cluster episode to shorten the headache cycle).
  • Migraine
  • Abortive therapy:
    • Mild migraine: acetaminophen, ASA, NSAIDs, combination analgesics (combination of any of the following: ASA, acetaminophen, caffeine).
    • Moderate to severe migraine: use migraine-specific drugs.  Triptans easier to use than ergotamines, with fewer side effects.
      • Triptans: Sumatriptan, rizatriptan, eletriptan, zolmitriptan all effective. Naratriptan mildest; Frovatriptan has longest ½ life; Contraindications: CAD, stroke, uncontrolled HTN, migraine with brainstem or hemiplegic aura, MAOIs, SSRIs
      • Ergotamine: less effective orally; C/I in CAD, PVD, pregnancy, triptans.
      • Isometheptene compound: i.e. Midrin – C/I in CAD, PVD – may not be available.
      • If severe nausea/vomiting: Nasal (sumatriptan or zolmitraptan), Subcutaneous (sumatriptan).  Also consider adding antiemetic (metoclopramide, prochlorperazine, or promethazine)
      • If poor response to initial triptan, consider 1) ↑ triptan dose, 2) trial of different triptan, 3) combination triptan/naproxen 4) DHE nasal spray (migranal)
      • Prophylactic therapy: recommend if 1) contraindications/intolerance to abortive tx, 2) HA > 2x/wk, 3) HA that severely limit quality of life despite abortive tx, 4) presence of uncommon migraine conditions. Start low, go slow: increase dose every 2-4 weeks. Maximal benefit may not be seen until 2-3 months after medication at target dose. Can discontinue after 6-12 months of control.
        • Beta-blockers – propranolol, atenolol, nadolol >> other BBs; consistent efficacy; s/e – fatigue, avoid in asthma
        • TCAs – amitriptyline 10 mg nightly initial dose; s/e – drowsiness, weight gain, anticholinergic effects, max dose 150 mg hs; nortriptyline 10-75 mg hs is a good alternative.
        • Anticonvulsants – divalproex500-1000 mg daily in 3 div doses but freq AEs, topiramate (start 25 mg/day, increase by 25 per week to 100 mg per day); AEs -  weight loss, fatigue, decreased appetite, nausea, diarrhea, cognitive dysfunction, paresthesias, kidney stones
        • Calcium-channel blockers (verapamil, amlodipine) – lower efficacy

When to Refer:

When diagnosis is unclear, patient has persistent symptoms despite first line prophylactic medications, or high disability.


Hainer BL, Matheson MM. Approach to Acute Headache in Adults. American Family Physician. 2013;87(10):682-687.

Simon, RP, Aminoff MJ, Greenberg DA (2017). Headache and Facial Pain. In Clinical Neurology, 10e. New york, NY: McGraw Hill.