10/12/21, 1:40 AM Headache - AMBOSS

Headache Last updated: Aug 30, 2021

QBANK SESSION CLINICAL SCIENCES CLINICIAN LEARNED

Summary
Headache is a symptom commonly encountered in everyday clinical practice, and, according to the WHO, one
of the ten most common causes of functional disability. It may be primary
(e.g., tension-type headaches, migraine) or secondary (e.g., following head trauma or infections) in nature.
Although most episodes of headache are harmless, potentially life-threatening causes (e.g., subarachnoid
hemorrhage, meningitis) should always be considered. Identifying the cause of headaches is often difficult
and requires a detailed clinical history as well as a thorough physical examination. Additional diagnostics, e.g.,
imaging, are only indicated if headaches persist despite treatment or if specific clinical features are present
that are signs of an underlying disease. This article gives an overview of the most common types of headache
and serves as a guide to diagnosing different headache disorders.
NOTES FEEDBACK

Approach
Approach to management
1. Check vital signs.
2. Perform focused history and examination.
3. If red flags are present:
Obtain brain imaging (either CT or MRI brain with and/or without contrast) based on the red flag symptoms. [1]
Perform further targeted diagnostics (see below).
4. If no red flags are present and suspicion for life-threatening causes is low:
Perform a detailed history and clinical exam.
Consider whether further diagnostic testing is necessary.
5. Provide supportive care.
6. Identify and treat the underlying cause.

Red flags for headache [1]

Sudden-onset severe headache (e.g., ”thunderclap headache”)
Fever
Focal neurological deficits
New headache at age > 50
Progressively worsening headache
Immunodeficiency (especially HIV)
Seizures
Meningeal signs
Psychiatric symptoms
Failure to respond to analgesics
“Worst headache of my life”
Visual deficits
Pregnancy or postpartum period
https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 1/10
10/12/21, 1:40 AM Headache - AMBOSS

Signs of increased ICP (e.g., papilledema)

Confusion or impaired level of consciousness
Life-threatening conditions [1]
Intracranial hemorrhage: subarachnoid hemorrhage, epidural hemorrhage, intracerebral hemorrhage
CNS infection: meningitis, encephalitis, brain abscess, subdural empyema
Conditions causing increased ICP
Hypertensive emergency
Internal carotid artery dissection
Vertebral artery dissection
Ischemic stroke
Pituitary apoplexy
Carbon monoxide poisoning
Cerebral venous sinus thrombosis
Hypoglycemia
Pre-eclampsia or eclampsia
Non-life-threatening conditions requiring urgent attention:
Acute angle-closure glaucoma
Giant cell arteritis
NOTES FEEDBACK

Definition
Headache is a pain related to irritation and/or inflammation of intracranial or extracranial structures
with painreceptors (e.g., meninges, cranial nerves, blood vessels).
Primary headache: a headache that is not caused by another underlying condition [2]
Includes migraine headache, tension headache, trigeminal autonomic cephalalgias (e.g., cluster headache)
Secondary headache: a headache that is caused by another underlying condition (e.g.,
trauma, space-occupyinglesion) [2]
NOTES FEEDBACK

Epidemiology
Lifetime prevalence: > 90%, with female predominance (except cluster headache) [3]
Most common forms of headache [3]
Tension-type headache: 40–80% of cases
Migraine: 10% of cases
Epidemiological data refers to the US, unless otherwise specified.
NOTES FEEDBACK

Etiology
See “Differential diagnoses” below.
NOTES FEEDBACK

Clinical features
https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 2/10
10/12/21, 1:40 AM Headache - AMBOSS

History of present illness

Timing
Duration of a single episode
Frequency
Clinical course (e.g., chronic, acute)
Nature of the headache
Localization
Character
Intensity
Radiation of pain
Severity (e.g., impact on patient's life)
Triggers and exacerbating factors
Altered sleep-wake cycle
Physical exertion
Stress
Certain types of food or alcohol
Fluctuations in hormone levels: oral contraceptives, menstruation
Lying down or standing up
Recent trauma
Associated symptoms
Nausea/vomiting
Horner syndrome
Aura
Photopsia, photophobia
Neck stiffness
Seizures
Change in vision
Lacrimation, rhinorrhea
New skin lesions
Allodynia of the head region
Past medical history, social history, and family history
Past medical history (e.g., hypertension, hypothyroidism, seizures, migraine, infections)
Medications (e.g., anticoagulants , analgesics, OCPs)
Allergies
Caffeine intake
Substance use
Alcohol consumption
Smoking
Family history
Physical examination
Vital signs
Blood pressure
Presence of fever
HEENT
Signs of trauma
Auscultation for bruits
Palpation of pericranial muscles
Palpation of the temporal artery and assessment of jaw movement
Palpation along the course of the trigeminal nerve
Examination of the teeth and oral cavity
Examination of the eye and extraocular movements
Assessment of cervical spine mobility
https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 3/10
10/12/21, 1:40 AM Headache - AMBOSS

Palpation of the sinuses

Direct fundoscopy
Neurological
Neurological examination for neurologic deficits
Signs of meningism
Abdomen: inspection and palpation of the abdomen
Skin: Evaluate for rash or signs of drug use.
Consider secondary life-threatening causes if red flags for headache are present!

NOTES FEEDBACK

Diagnostics
Approach [4]
Diagnostic evaluation should be performed based on risk stratification and the suspected diagnosis.
Low-risk headache: No routine laboratory tests or imaging are recommended.
High-risk headache: Consider diagnostic workup based on the suspected diagnosis.
Primary headache is a clinical diagnosis and typically does not require laboratory or imaging evaluation.
Risk stratification of headache [4][5]
MAXIMIZE TABLE TABLE QUIZ
Clinical features
Age < 30 years
Features of primary headache
Prior experience of similar headache
Low-risk headache Absence of neurologic deficits
Typical headache pattern
No recent history of cancer, HIV, or Lyme disease
No red flags for headache
Any red flags for headache
Any features of secondary headache
Horner syndrome
High-risk headache Accompanying systemic illness (e.g., fever, myalgias)
Triggered by cough, exertion, or sexual intercourse
Tenderness over the temporal artery
History of cancer, HIV, Lyme disease

Laboratory studies
There are no routine recommended laboratory studies for headaches. Consider the following based on clinical
suspicion:
CBC
TSH
ESR, CRP
Imaging [6]
Test of choice
The initial test of choice is usually a head CT without contrast.
See the table below for other imaging modalities to consider.
https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 4/10
10/12/21, 1:40 AM Headache - AMBOSS
MAXIMIZE TABLE TABLE QUIZ
Recommended initial imaging modality for headache [7]
Initial test of choice Alternatives
Sudden-onset severe headache (i.e., thunderclap headache) CT head without IV contrast CTA with IV contrast
CTV head with IV
contrast
MRI head MRV head
New headache with papilledema Without contrast Without IV contrast
Without and with IV contrast Without and with IV
CT head without IV contrast contrast
CT head with IV
contrast
CT head without IV contrast
New or worsening headache related to head trauma or MRI head N/A
accompanied by red flags Without IV contrast
Without and with IV contrast
New primary headache suspected to be of trigeminal autonomic MRI head without and with IV MRI head without IV
origin contrast contrast
(e.g., cluster headache)

MRI head CT head

Chronic headache with new features or change in character, Without IV contrast Without and with IV
severity, or frequency contrast
Without and with IV contrast Without IV contrast

Additional diagnostics to consider [6]

Lumbar puncture (LP) with CSF analysis: for suspected meningitis, suspected inflammatory process
or malignancy, or if there is a high suspicion of SAH without proof on CT scan
Tonometry: if increased intraocular pressure is suspected
EEG: for any form of suspected seizures or complex migraine
Temporal artery biopsy: if GCA is suspected
The diagnostic modality should be determined by the patient history and clinical
presentation. Neuroimaging is usually not indicated for primary or low-risk headaches.

NOTES FEEDBACK

Primary headaches
MAXIMIZE TABLE TABLE QUIZ
Types of primary headaches
Tension headache Migraine headache Cluster headache
Sex ♀ >♂ ♀ >♂ ♂ > ♀ (3:1)

Duration 30 minutes to a couple of days 4–72 hours 30–180 minutes

Short, recurring attack

https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 5/10
10/12/21, 1:40 AM Headache - AMBOSS

Types of primary headaches

Tension headache Migraine headache Cluster headache

Occasionally to daily Occasionally to several times 1–3 episodes every 24 h

Frequency Episodic or chronic a month Usually occur in a cyclic
(clusters)
Mostly unilateral
Localization Holocephalic or bifrontal 60% are unilateral. Localized to the periorb
temporal region
Often burning or piercin
Dull, Pulsating, Attacks develop within s
Character nonpulsating, band-like or vise-like pain boring/hammering pain minutes
Constant Often wakes patients up
sleep
Severe, agonizing pain
Because of the severity
Intensity Mild to moderate Moderate to severe some patients report
experiencing suicidal
thoughts (hence the
name “suicidal headache

Nausea, vomiting Ipsilateral autonomic

Maximum of one autonomic symptom Hyperacusis symptoms: conjunctiva
(phonophobia, or photophobia) Photophobia and/or lacrimation, rhino
Additional symptoms No nausea, vomiting, or aura Phonophobia nasal congestion
Tightness in the posterior neck muscles Preceding aura Partial Horner
Pericranial tenderness Prodrome syndrome: ptosis and m
no anhidrosis
Stress
Fluctuation
Stress in hormone levels: oral
Triggers/exacerbating Lack of sleep, fatigue contraceptives, menstruation
factors Routine activities (e.g., climbing stairs) Certain types of food (e.g., Alcohol
do not exacerbate symptoms. those containing tyramines
or nitratessuch as processed
meat, chocolate, cheese)
Exacerbated by exertion

The typical migraine headache can be remembered by

“POUND”: pulsatile, one-day duration, unilateral, nausea, disabling intensity.

NOTES FEEDBACK

Secondary headaches
MAXIMIZE TABLE TABLE QUIZ

https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 6/10
10/12/21, 1:40 AM Headache - AMBOSS

Diagnosis Clinical features Diagnostic findings

Classic triad: fever, headache, and
neck stiffness(nuchal rigidity) ↑ WBC, ↑ procalcitonin (if bacterial)
Meningism (e.g., photophobia) CSF analysis
Meningitis [11][12][13] Dull, diffuse (holocephalic) headache Bacterial: WBC ≥ 1000 cells/μL (predominan
that worsens over hours/days glucose, positive gram stain
Altered mental status Viral: WBC 10-500 cells/μL (predominantly ly
Nausea, vomiting normal glucose
Seizures
Acute, severe, nonspecific headache
Focal neurologic signs and symptoms
Intracerebral hemorrhage [14][15] Nausea and vomiting CT head without contrast: hyperdense lesion
Confusion and loss of consciousness
Seizures
Acute onset of a thunderclap headache
Focal neurologic deficits
Subarachnoid hemorrhage [16] Meningism CT head without contrast: blood in subarach
Impaired consciousness, rapidly Lumbar puncture : ↑ RBC count
worsening neurological status
Seizures
Diffuse headache that is worst on the
side of the hematoma
Impaired
consciousness and confusion
Focal neurologic CT head without contrast: crescent-shaped,
Subdural hematoma(SDH) deficits (e.g., hemiparesis , gait, speech, that crosses suture lines but not the midline
visual impairment, personality changes,
dilated pupil , or nonreactive pupil )
Signs of increased intracranial pressure
Chronic subdural hemorrhage
: psychomotor impairment, memory loss
Headache localized to the side of
the hematoma
Contralateral focal
symptoms/hemiplegia
Impaired mental status, loss of
Epidural hematoma[17] consciousness, seizures, nausea, and CT head without contrast: biconvex, hyperd
vomiting
Nearly half of patients who lose
consciousness will have a lucid
interval followed by clinical deterioration
due to further expansion.

https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 7/10
10/12/21, 1:40 AM Headache - AMBOSS

Diagnosis Clinical features Diagnostic findings

Nonspecific headache (acute, subacute,
or chronic)
Cranial nerve symptoms
(e.g., diplopia, tinnitus, unilateral
deafness, facial palsy)
Cavernous sinus syndrome Labs: ↑ WBC , ↑ D-dimer
Cerebral venous sinus Focal neurological deficits Fundoscopy: papilledema
thrombosis [18] Seizures MRI/MRV or CT/CTV: direct or indirect signs
Impairment in consciousness and in cerebral venous thrombosis) [19]
awareness Cerebral venography: filling defect [18]
Signs of increased intracranial
pressure (e.g., nausea, vomiting)
Risk factors: pregnancy, prothrombotic
states, vasculitis, smoking, use of oral
contraceptives
Unilateral headache over the
temporal/occipital area
Prominent, tender temporal artery
Jaw claudication, scalp tenderness
Constitutional symptoms: fever, malaise, Anemia, ↑ ESR ≥ 40–50 mm/hour , ↑ CRP, ↑
Giant cell arteritis [20][21][22][23] fatigue Temporal artery biopsy (gold standard): seg
If temporal arteritis is associated predominant mononuclear cells or granulom
with polymyalgia rheumatica: MRI with contrast: enhancement of the temp
shoulder/pelvic pain, depression,
tiredness, fever, weight loss
Partial or complete vision loss (unilateral
or bilateral), amaurosis fugax, diplopia
Diffuse (sometimes bifrontal), pulsating
headache that is exacerbated by Clinical diagnosis: elevated BP with or witho
physical activity Labs: anemia, ↑ creatinine, ↑ BNP, proteinu
Hypertensive crises[24][25] Hypertension > 180/120 mm Hg ECG: left ventricular hypertrophy, signs of ca
Signs of end-organ damage (e.g., chest depressions or elevations)
pain, dyspnea, oliguria, altered mental Chest x-ray: cardiomegaly, pulmonary edem
status)

Tension-type headache CT head without contrast: hyperdense occlu

Ischemic stroke [26][27] Focal neurological deficits effacement of the sulci and loss of corticom
Altered mental status CTA head and neck: vessel occlusion
DW-MRI: T1 hypointense signal, T2 hyperinte
A dull headache that is usually bifrontal
and worsens over weeks/months T1-weighted MRI brain with gadolinium: hyp
Intracranial space-occupyinglesions Signs of increased intracranial with peritumoral edema
(e.g., brain tumors) [28][29][30] pressure (e.g., papilledema)
Focal neurologic deficits, altered mental CT brain with IV contrast: mass lesion, comm
status, seizures, nausea and vomiting
Headache of variable intensity
Confusion
Retrograde amnesia and/or anterograde
Concussion (e.g., mild traumatic amnesia Clinical diagnosis
brain injury) [31][32][33] Nausea, vomiting, dizziness CT head without contrast: usually normal
Ageusia , anosmia, tinnitus, photophobia,
blurring of vision
Loss of consciousness (rare)
History of trauma

https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 8/10
10/12/21, 1:40 AM Headache - AMBOSS

Diagnosis Clinical features Diagnostic findings

Paroxysmal (seconds to 2 minutes) and
stabbing pain
Unilateral facial pain, strictly localized to
the distribution of the branches of
the trigeminal nerve Clinical diagnosis [35]
Trigeminal neuralgia [34][35] Frequency and intensity of episodes MRI brain: vascular compression of the trige
usually increase over time
Tender trigger points
Triggered by chewing, talking, cold, and
touching specific areas of the face
No neurologic deficits
Headache with variable characteristics
History of analgesic overuse
Medication overuse headache Autonomic symptoms (e.g., nausea) Clinical diagnosis
Cognitive or behavioral symptoms (e.g.,
comorbid depression)

NOTES FEEDBACK

Differential diagnoses
Primary headache
Migraine
Tension-type headache
Trigeminal autonomic cephalalgias: cluster headaches, paroxysmal hemicrania, hemicrania continua
Other primary headaches: cough headaches, headaches due to physical exertion, postcoital
headache, primary stabbing headache
Secondary headache
Bleeding
Epidural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Intracerebral hemorrhage
Vascular
Cerebral venous thrombosis
Pituitary apoplexy
Stroke, TIA
Aneurysms
Carotid artery dissection
Vertebral artery dissection
Autoimmune
Temporal arteritis
Drug/toxin-related
Alcohol use
Alcohol withdrawal
Food additives (e.g., MSG)
Sympathomimetics (e.g., nicotine)
Medication overuse headache
Caffeine withdrawal headache
Opioid withdrawal
https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 9/10
10/12/21, 1:40 AM Headache - AMBOSS

Nitroglycerin
Carbon monoxide poisoning
Infectious
Intracranial infections
Meningitis
Encephalitis
Brain abscess
Subdural empyema
Aseptic meningitis
Toxoplasmosis
Systemic infections (e.g., influenza)
Other
Increased intracranial pressure
Decreased intracranial pressure (e.g., post-lumbar puncture headache)
Hydrocephalus
Glaucoma
Brain tumors
Trigeminal neuralgia
Giant cell arteritis
Hypoxia and/or hypercapnia (e.g., high-altitude headache)
Hypertension
Hypoglycemia
Hypothyroidism
Iridocyclitis
Refractive errors
Rhinosinusitis
Postictal headache
Cervicogenic headache (e.g., cervical disc disease)
Temporomandibular joint disorders
Postherpetic neuralgia
Optic neuritis
Psychiatric
Somatization disorder
Psychotic disorder
The differential diagnoses listed here are not exhaustive.

https://next.amboss.com/us/article/YL0nwg?q=Headache#Z67ba0252fff6842349617790ed19ae54 10/10