Definition
Pain in any region of the head that may relate to a process affecting pain-sensitive structures within the head, neck, and face.
Differential Diagnosis
- Primary headache syndrome: migraine (+/- aura), tension, trigeminal autonomic cephalgia (e.g. cluster headache)
- Secondary headache disorder: tumor, subarachnoid hemorrhage, meningitis, giant cell (temporal) arteritis, disorder of intracranial pressure, etc.
Evaluation
- History: qualities of headache: new vs. old, time/rapidity of onset (i.e. is pain maximal at onset), location, character (dull, throbbing, stabbing); medication use; positional/diurnal variation; medical comorbidities (especially history of cancer, immunosuppression)
- Highly likely to be migraine if the headache is described as pulsating, duration 4-72 hours, unilateral, nausea, disabling (positive likelihood of 24 if 5/5 features present; LR of 3.5 if 3/5 are present)
- Physical:
- General exam: look for signs of systemic illness (e.g. fever, weight loss) that could indicate infection or cancer; palpate scalp, face, and neck for focal areas of tenderness (e.g. temporal artery pain)
- Look for nuchal rigidity (indicates meningeal irritation)
- Full neurological exam including fundoscopic exam to look for papilledema
- “Red flag” features:
- Age > 50
- Sudden onset
- Positional (routinely worse while supine [indicates high ICP] or upright [possible low ICP]) or wakes patient from sleep
- Rapid onset after trauma or strenuous exercise
- Fever
- Associated with focal neuro signs/symptoms
- New headache in immunosuppressed patient
- Pregnant or recent post-partum
|
Headache |
History |
Exam |
Workup |
Treatment |
|
Migraine |
Throbbing pain, lasts hours to days; +/- triggers (e.g. missed meals, alcohol, meds, menstruation, time of day), photo/phonophobia; nausea/vomiting, visual aura. |
Scalp allodynia; rarely focal neuro signs during HA |
None |
Abortive: NSAIDs, triptans, ergots, prochlorperazine Prophylactic: first line topiramate, valproic acid, propranolol, amitriptyline, botox, CGRP antagonists |
|
Tension |
Chronic, frequent episodes of non-throbbing, “band-like” pain |
Unremarkable |
None |
Abortive: same as migraine Prophylactic: TCAs, behavioral modification, trigger point injections |
|
Cluster |
Clusters (occurring days to months) of brief (min-hours), severe, unilateral HAs, usually peri-orbital with autonomic features (lacrimation, rhinorrhea, congestion, periorbital edema) |
Ipsilateral conjunctival injection; possible Horner syndrome during attacks |
None |
Sumatriptan 4-6 mg SC or IN plus high flow (>7L/min) O2 via face mask Prophylactic: first line verapamil; prednisone taper, lithium |
|
Trigeminal neuralgia |
Brief jabs of excruciating electrical pain over V2/V3 region of face; light touch/talking/teeth brushing can trigger pain |
Patient exhibits intense pain with even light touch of affected area |
MRI/MRA brain w/wo contrast (w/ indication “facial pain c/f trigeminal neuropathy”) |
Carbamazepine, oxcarbazepine, phenytoin, lamotrigine, baclofen; decompressive surgery |
|
Analgesic overuse headache |
Chronic HA treated w/ escalating doses of analgesics (esp. opiates, caffeine-containing, triptans ) |
Unremarkable |
None |
Taper pain meds, can bridge with naproxen or steroids |
|
Tumor |
Daily pain, worse in morning or lying down; +/- history of cancer |
Papilledema, focal neuro signs |
MRI brain w/wo contrast |
Treat tumor as appropriate |
|
SAH |
Sudden onset, new HA; may be associated w/ exertion; +/- history of PCKD, family h/o aneurysms |
HTN, fever, nuchal rigidity, AMS, focal neuro deficit or comatose |
Non-contrast head CT, LP, angiography |
BP control, nimodipine to prevent vasospasm, consult neurosurgery or neuro IR for surgical or endovascular management |
|
Meningitis |
Fever/chills, neck stiffness, photophobia, phonophobia |
Fever, nuchal rigidity, jolt accentuation of headache, AMS |
Blood cultures, LP (CT 1st if concern for elevated ICP, focal neuro deficit, seizure, history of immunosuppression or known CNS disease) |
Meningeal dosing of antibiotics:
|
|
Giant cell (temporal) arteritis |
Pain over temples, jaw claudication, fever, PMR, weight loss, amaurosis fugax |
Palpable, tender temporal artery |
ESR and CRP, formal ophthalmologic exam, artery biopsy |
High dose corticosteroids |
Choosing Wisely
- Don’t perform electroencephalography (EEG) for headaches. EEG has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes and increases cost. Recurrent headache is the most common pain problem, affecting 15% to 20% of people.
- Don’t use opioid or butalbital treatment for migraine. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions such as tumor-related headache, if needed.
Key points
- A careful headache history can often tell you more than lab work or physical exam can; in particular, pay close attention to “red flag” features, such as positional variability or focal neuro symptoms.
- New headaches or headaches with sudden onset are frequently more concerning than chronic headaches or those that come on gradually.
- Imaging is not always recommended in patients with a new headache, but should typically be done in older patients (age > 50), immunosuppressed patients, patients with a fever, and patients with focal neurological deficits.
Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296(10):1274-1283. doi:10.1001/jama.296.10.1274