Acute headache: diagnosis

Stephanie J Nahas MD (

Dr. Nahas of Thomas Jefferson University received honorariums from Allergan, Amgen/Novartis, Electrocore, Eli Lilly, Supernus, and Teva for speaking engagements and from Allergan, Amgen/Novartis, Biohaven, Eli Lilly, Impel, Lundbeck, Supernus, Teva, Theranica, and Zosano for consulting work.

)
Shyam C Majmundar MD (

Dr. Majmundar of Thomas Jefferson University has no relevant financial relastionships to disclose.

)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, received honorariums from Abbie, Curelator, Ipsen Therapeutics, Lundbeck Biopharmaceuticals, Supernus Pharmaceuticals,  and Theranica for consulting. He is also the  principal investigator for clinical trials conducted by Amgen, ElectroCore Medical, and Teva.

)
Originally released October 21, 2004; last updated December 7, 2020; expires December 4, 2023

This article incudes discussion of diagnosis of acute headache; migraine; thunderclap headache; tension-type headache; headache with systemic illness or systemic symptoms; migraine aura; headache triggered by cough, exertion, orgasm, or direct stimuli; headache during pregnancy or postpartum; positional headache; headache in the elderly; sinus symptoms and headache; and ocular disorders. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Headache is a common chief complaint in acute settings. The diagnosis of acute headache can be challenging and should proceed in an orderly fashion. An important first step is to distinguish primary from secondary headache disorders. The approach is to seek “red flags” in the history and exam that suggest the possibility of secondary headache. If red flags are identified, the clinician must entertain potential secondary diagnoses and proceed with the appropriate diagnostic investigations. In the absence of secondary headache, the clinician diagnoses a primary headache disorder.

Key points

 

• Migraine is the most common diagnosis in the evaluation of acute headache.

 

• Secondary causes must be ruled out in all cases of acute headache presentation, mainly based on “red flags” uncovered in the history and physical/neurologic examination.

 

• A systematic approach to the headache, characterizing it in terms of duration, quality, location, and accompanying symptoms, speeds the diagnosis.

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