Clinical Practice

Acute Headache
in Adults

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 Definition
Headache is pain localized to any part of
the head, behind the eyes or ears, or in
the upper neck.
Hallmark physical signs are often absent,
and many physical findings are non-
specific.
The majority of patients presenting with
acute headache have a benign diagnosis,
but a high index of suspicion should be
maintained for life-threatening causes of
headache.

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 Etiology
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
o Sudden onset
o Subarachnoid hemorrhage
o CVA
o Venous sinus thrombosis
o Meningitis
o Hypertensive encephalopathy
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 o Pituitary apoplexy
o Duration of hours to days
o Tension headache
o Migraine
o Episodic, 2 to 10 episode/day, lasting
seconds to minutes
o Cluster headache
o Trigeminal neuralgia
o Awaken from sleep/morning headache
o Intracranial mass

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Precipitating factors
o Trauma
o Subdural hematoma
o Subarachnoid hemorrhage
o Epidural hematoma
o Concussive syndrome
o Increasing severity and frequency
o Mass lesion
o Subdural hematoma
o Recent high-attitude changes
o Hypoxia/acute mountain sickness
o Fatigue or stress
o Tension headache

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 o Valsalva (coughing, sneezing, bending or
exertion)
o Intracranial lesion (posterior fossa)
o Aligned with menstrual cycle
o Menstrual headache
o Medication changes/withdrawal (caffeine,
opiates, pseudoephedrine)

Associated symptoms
o Fever
o Systemic infection
o Meningitis
o Encephalitis
o Brain abscess
o Otitis media

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o Vomiting
o Mass lesion
o Brain abscess
o Migraine
o Carbon monoxide poisoning
o Seizure
o Mass lesion
o CVA
o Meningitis
o Encephalitis
o Metabolic
o Toxic
o Dizziness
o Ischemic or hemorrhagic infarct (posterior
fossa)
o Migraine
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o Warning signs: visual, auditory, gustatory
disturbance
o Migraine with aura
o Neck pain
o Meningitis
o Subarachnoid hemorrhage
o Tension headache
o Musculoskeletal pain (cervical paraspinal
muscle pain)
o Facial pain
o Temporal area
o Temporomandibular joint syndrome
o Giant cell arteritis
o Trigeminal neuralgia

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 o Eye area: glaucoma
o Ear area: otitis media
o Sinusitis
o Visual disturbance
o Migraine
o Acute angle-closure glaucoma
o Lacrimation, rhinorrhea
o Cluster headache
o Sinus headache

Medical history
o HIV/AIDS or immunocompromised
o Meningitis
o Encephalitis

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o Age > 50 with new onset headache
o Mass lesion
o Giant cell arteritis
o COPD
o Hypoxia
o Connective tissue disorder (e.g SLE)
o Cerebral vasculitis
o Cancer
o Brain metastases
o Hypertension
o Hypertensive headache
o Family history
o Migraines

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 Urgent considerations
o Meningitis
o Present with fever, headache, neck stiffness
o If LP is delayed for CT, blood cultures should be
obtained and broad-spectrum antibiotic given
before CT
o If high suspicion, antibiotic should be
administered empirically before LP
o Epidural hematoma
o History of blunt head trauma at
temporoparietal aspect of skull
o Immediate CT

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o Subdural hematoma
o History of alcohol misuse, coagulopathy,
trauma
o Immediate CT.
o Subarachnoid hemorrhage (SAH)
o It may present with a thunderclap headache
(sudden onset of severe headache, seen in
12% of SAH) or with a sentinel (a mild
headache preceding the severe one, seen in
< 10%), usually in women aged 40 to 60
years
o Sudden onset, worst headache of life
o Immediate CT or MRI

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o Hypertensive encephalopathy
o Elevated BP, mean arterial pressure > 150 to
200 mmHg
o Immediate CT
o BP should be quickly lowered by 20% to 25%
(labetalol, nicardipine)
o Eclampsia/pre-eclampsia
o Elevated BP in pregnant or peripartum
patients
o May also have proteinuria, pedal edema,
seizure
o Obs & Gyn consultant for safe BP

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o Giant cell arteritis
o Patient > 50 years, with their first severe
headache
o ESR is checked
o Immediate treatment with corticosteroids is
required to prevent blindness if diagnosis is
suspected
o Acute angle-closure glaucoma
o Headache in older person (>50 years)
o Decreased visual acuity, nausea/vomiting,
eye pain, mid-dilated fixed pupil
o Intra-ocular pressure should be reduced
(pilocarpine, timolol, acetazolamide)
o Ophthalmology consultation

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 Step-by-step diagnostic
approach
History of present illness
Isthis worst headache of their life?
Yes, consider subarachnoid hemorrhage (SAH)
Isthis a typical headache?
Yes, manage with analgesic medication, rest,
hydration
Did the patient typical headache improve after
conventional treatment?
Yes, follow up with headache specialist
No, consider other diagnosis
Maybe: consider other causes
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 When did the headache begin?
Sudden onset, unprovoked: SAH, CVA (25%
sudden onset headaches are SAH)
Sudden onset, provoked by exertion, orgasm,
cough, sneeze, benign transient intracranial
pressure increase, SAH
Subacute, progressive over weeks to months;
intracranial lesions (i.e, tumor/mass), subdural
hematoma, hydrocephalus
Is the patient older than 50, with their first
headache?
Immediate considerations: giant cell arteritis

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 What are the exacerbating factors?
Erect position: mass lesions
Exertion or Valsalva: mass lesions
Worse in the morning: carbon monoxide
mass lesions
Foods: caffeine, monosodium glutamate

Review of symptoms

Does the patient have a fever?

Immediate considerations: meningitis,
encephalitis, brain abscess
Other considerations: viral syndrome,
dehydration

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 Did the patient vomit?
Immediate considerations: meningitis, CVA,
subarachnoid hemorrhage (SAH), subdural
hematoma, epidural hematoma
Other considerations: migraine, carbon
monoxide poisoning, pseudotumor cerebri
Does the patient have visual complaints?
Visual disturbance: CVA, meningitis, migraine,
acute angle-closure glaucoma, giant cell
arteritis, pseudotumor cerebri, venous sinus
thrombosis
Photophobia: meningitis, migraine

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 Did the patient have a seizure?
Immediate considerations: mass lesions,
meningitis, encephalitis, CVA, toxic, or
metabolic causes
Other considerations: migraine
Did the patient have confusion or altered
mental status?
Immediate considerations: SAH, CVA,
meningitis, encephalitis
Does the patient have dizziness?
Immediate considerations: CVA
Others considerations: migraine, carbon
monoxide poisoning, pseudotumor cerebri

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 Does the patient have weakness or focal
neurological deficits?
Immediate considerations: CVA, SAH
Other considerations: migraine with aura
Does the patient have neck pain?
Immediate considerations: meningitis, SAH
Others: tension headache, musculoskeletal
pain (paraspinal muscle strain/tension).
Is there recent head trauma?
Immediate considerations: subdural
haematoma, SAH, epidural haematoma
Urgent considerations: concussion

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 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 joint syndrome, trigeminal
myalgia, dental pain
Does the patient also 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)

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 Isthe patient pregnant or recently postnatal?
Consider pre-eclampsia or eclampsia
Isthe patient female?
Premenstrual, perimenopausal, contraceptive
pill
Does the patient have COPD or hx of chronic
cigarette smoking?
Consider hypoxia or hypercarbia
Are other family members or pets sick?
Consider carbon monoxide poisoning

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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 FHx?
Consider migraine
Consider brain tumor (primary cancer or
brain metastasis).
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 Physical examination
Vital signs and vital considerations

Elevated BP: consider hypertensive emergency,

hypertensive urgency
Temperature: consider infectious source
If increased ICP, may see Cushing's response
(hypertension, bradycardia, and bradypnoea).
Head, eyes, ears, nose and throat (HEENT)
Listening for bruit at neck, eyes, and head: AV
malformation
Palpation of head and neck for tenderness:
paraspinal muscle tenderness/tension headache

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 Tenderness over frontal and/or maxillary sinuses:
consider sinusitis
Tenderness over temporomandibular joint: TMJ
dysfunction
Neck stiffness/meningismus: meningitis
Palpation of temporal artery for tenderness:
giant cell arteritis
Funduscopy and Snellen chart: papilloedema
(causes of raised ICP)
Dental examination: caries/wisdom tooth
impaction
Ear examination: otitis media

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Focused physical examination

Extracranial structure 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 neurological examination
Assessment of orientation, consciousness
(Glasgow coma scale), presence of confusion
and memory impairment

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 Ophthalmology examination to include pupillary
symmetry and reactivity, optic fundi, visual fields,
and ocular motility
Cranial nerve examination to include corneal
reflexes, facial sensation, and facial symmetry
Symmetrical muscle tone, strength (may be as
subtle as arm or leg drift), or deep tendon reflexes
Sensation
Plantar response: gait, arm, and leg co-ordination
Abnormal plantar reflex (Babinski's sign): positive
in CNS lesions
Painful knee extension with hip flexed (Kernig's
sign); 5% positive in meningism
Hip flexion with neck flexion (Brudzinski's sign):
5% positive in meningism.
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 Investigations
CT brain
When considering SAH, CVA, subdural
hematoma, epidural hematoma, meningitis,
sinus venous thrombosis, pseudotumor
cerebri.
MRI brain
When considering mass lesion, brain tumour
Lumbar puncture
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)
Has a fever (brain abscess, meningitis,
encephalitis)
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 Has neck stiffness (SAH, meningitis)
Is young, overweight, and female (sinus
venous thrombosis, pseudotumor cerebri)
After negative CT when considering SAH,
meningitis, pseudotumor cerebri
Laboratory tests
ESR, when considering giant cell arteritis
ABG, when considering hypoxia or
hypercapnia
Carboxyhaemoglobin, when considering
carbon monoxide poisoning
A pulse CO-oximeter may reveal elevated
CO levels, but this test is not widely
available
FBC and liver function tests are performed if
pre-eclampsia is suspected. Urinalysis is also
required in these patients
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 Differential diagnosis
Common

Acute sinusitis
Otitis media
Menstrual headache
Medication withdrawal
Medication overuse
Cervical paraspinal muscle tenderness
Migraine

Tension headache
Dental caries/wisdom tooth impaction
Medical
Temporomandibular joint Visit
syndrome
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 Uncommon

Benign intracranial hypertension (pseudotumor

cerebri)
Brain tumor
Hypertensive encephalopathy
Eclampsia/pre-eclampsia
Pituitary apoplexy
Venous sinus thrombosis
Epidural hematoma
Subarachnoid hemorrhage (SAH)
Subdural hematoma
Meningitis
Brain abscess
Carbon monoxide poisoning
Concussive syndrome/trauma
Acute mountain
Medicalsickness/hypoxia
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