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Evaluationofheadacheinadults

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Evaluationofheadacheinadults
Authors
ZahidHBajwa,MD
RJoshuaWootton,MDiv,PhD

SectionEditor
JerryWSwanson,MD,MHPE

DeputyEditor
JohnFDashe,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Mar2016.|Thistopiclastupdated:Jan22,2016.

INTRODUCTIONHeadacheisamongthemostcommonmedicalcomplaints.Anoverviewoftheapproachto
thepatientwithheadacheispresentedhere.Theapproachtoadultspresentingwithheadacheintheemergency
departmentisreviewedelsewhere.(See"Evaluationoftheadultwithheadacheintheemergencydepartment".)
Theclinicalfeaturesandmanagementofspecificprimaryheadachesyndromesarediscussedseparately.(See
"Pathophysiology,clinicalmanifestations,anddiagnosisofmigraineinadults"and"Tensiontypeheadachein
adults:Pathophysiology,clinicalfeatures,anddiagnosis"and"Clusterheadache:Epidemiology,clinicalfeatures,
anddiagnosis".)
EPIDEMIOLOGYANDCLASSIFICATIONAsmanyas90percentofallbenignheadachesfallunderafew
categories,includingmigraine,tensiontype,cluster,andchronicdailyheadache.Whileepisodictensiontype
headacheisthemostfrequentheadachetypeinpopulationbasedstudies,migraineisthemostcommondiagnosis
inpatientspresentingtoprimarycarephysicianswithheadache.Theoneyearprevalenceofepisodictensiontype
headache(TTH)isapproximately65percent(see"Tensiontypeheadacheinadults:Pathophysiology,clinical
features,anddiagnosis",sectionon'Epidemiology'),butmostpeoplewithtensiontypeheadachedonotpresentto
physiciansforcare.Asanexample,astudyoftwoprimarycareunitsinBrazilfoundthatmigrainewasthemost
prevalentprimaryheadachedisorder,accountingfor45percentofpatientsreportingheadacheasasingle
symptom[1].
Clusterheadachetypicallyleadstosignificantdisabilityandmostofthesepatientswillcometomedicalattention.
However,clusterheadacheremainsanuncommondiagnosisinprimarycaresettingsbecauseofoveralllow
prevalenceinthegeneralpopulation(<1percent).(See"Clusterheadache:Epidemiology,clinicalfeatures,and
diagnosis",sectionon'Epidemiology'.)
Clinicianscaneasilybecomefamiliarwiththemostcommonprimaryheadachedisordersandhowtodistinguish
them(table1).
MigraineMigraineisadisorderofrecurrentattacks.Theheadacheofmigraineisoftenbutnotalwaysunilateral
andtendstohaveathrobbingorpulsatilequality.Accompanyingfeaturesmayincludenausea,vomiting,
photophobia,orphonophobiaduringattacks.(See"Pathophysiology,clinicalmanifestations,anddiagnosisof
migraineinadults".)
Migrainetriggerfactors(table2)mayincludestress,menstruation,visualstimuli,weatherchanges,nitrates,
fasting,wine,sleepdisturbances,andaspartame,amongothers.(See"Pathophysiology,clinicalmanifestations,
anddiagnosisofmigraineinadults",sectionon'Precipitatingandexacerbatingfactors'.)
TensiontypeheadacheThetypicalpresentationofaTTHattackisthatofamildtomoderateintensity,
bilateral,nonthrobbingheadachewithoutotherassociatedfeatures.PureTTHisaratherfeaturelessheadache.
(See"Tensiontypeheadacheinadults:Pathophysiology,clinicalfeatures,anddiagnosis".)
ClusterheadacheClusterheadachebelongstoagroupofidiopathicheadacheentities,thetrigeminal
autonomiccephalalgias(table3),allofwhichinvolveunilateral,oftensevereheadacheattacksandtypical
accompanyingautonomicsymptoms.Clusterheadacheischaracterizedbyattacksofsevereunilateralorbital,
supraorbital,ortemporalpainaccompaniedbyautonomicphenomena.Unilateralautonomicsymptomsare

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ipsilateraltothepainandmayincludeptosis,miosis,lacrimation,conjunctivalinjection,rhinorrhea,andnasal
congestion.Attacksusuallylast15to180minutes.(See"Clusterheadache:Epidemiology,clinicalfeatures,and
diagnosis".)
Clusterheadachemaysometimesbeconfusedwithalifethreateningheadache,sincethepainfromacluster
headachecanreachfullintensitywithinminutes.However,clusterheadacheistransient,usuallylastinglessthan
onetotwohours.
SecondaryheadachePhysicianswhoevaluatepatientswithheadacheshouldbealerttosignsthatsuggesta
seriousunderlyingdisorder.(See'Dangersigns'belowand'Patientsettings'below.)
IntheBrazilianprimarycarestudy,39percentofpatientspresentingwithheadachehadaheadachethatwasdue
toasystemicdisorder(mostcommonlyfever,acutehypertension,andsinusitis),and5percenthadaheadache
thatwasduetoaneurologicdisorder(mostcommonlyposttraumaticheadache,headachessecondarytocervical
spinedisease,andexpansiveintracranialprocesses)[1].
MisconceptionsAnumberofmisconceptionsmayhinderheadacheevaluationanddiagnosis.
Althoughsinusheadacheiscommonlydiagnosedbyphysiciansandselfdiagnosedbypatients,acuteor
chronicsinusitisappearstobeanuncommoncauseofrecurrentheadaches,andmanypatientspresenting
withsinusheadacheturnouttohavemigraine[24].(See'Sinussymptoms'below.)
Patientsfrequentlyattributeheadachestoeyestrain.However,anobservationalstudysuggestedthat
headachesareonlyrarelyduetorefractiveerroralone[5].Nevertheless,correctingvisionmayimprove
headachesymptomsinsomeofthesepatients.
Thereisacommonbelief,particularlyamongpatients,thathypertensioncancauseheadaches.Whilethisis
trueinthecaseofhypertensiveemergencies,itisprobablynottruefortypicalmigraineortension
headaches.Asanexample,areportfromthePhysicians'HealthStudyof22,701Americanmalephysicians
ages40to84yearsanalyzedvariousriskfactorsforcerebrovasculardiseaseandfoundnodifferenceinthe
percentageofmenwithahistoryofhypertensioninthemigraineandnonmigrainegroups[6].Furthermore,a
prospectivestudyof22,685adultsinNorwayfoundthathighsystolicanddiastolicpressureswereactually
associatedwithareducedriskofnonmigrainousheadache[7].
EVALUATIONTheappropriateevaluationofheadachecomplaintsincludesthefollowing:
Ruleoutseriousunderlyingpathologyandlookforothersecondarycausesofheadache.
Determinethetypeofprimaryheadacheusingthepatienthistoryastheprimarydiagnostictool(table1).
Theremaybeoverlapinsymptoms,particularlybetweenmigraineandtensiontypeheadacheandbetween
migraineandsomesecondarycausesofheadachesuchassinusdisease.
Asystematiccasehistoryisthesinglemostimportantfactorinestablishingaheadachediagnosisand
determiningthefutureworkupandtreatmentplan.Animagingstudyisnotnecessaryinthevastmajorityof
patientspresentingwithheadache.Nevertheless,brainimagingiswarrantedinthepatientswithdangersigns
suggestingasecondarycauseofheadache.(See'Indicationsforimagingstudies'below.)
HistoryandexaminationAthoroughhistorycanfocusthephysicalexaminationanddeterminetheneedfor
furtherinvestigationsandneuroimagingstudies.Asystematichistoryshouldincludethefollowing:

Ageatonset
Presenceorabsenceofauraandprodrome
Frequency,intensity,anddurationofattack
Numberofheadachedayspermonth
Timeandmodeofonset
Quality,site,andradiationofpain

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Associatedsymptomsandabnormalities
Familyhistoryofmigraine
Precipitatingandrelievingfactors
Effectofactivityonpain
Relationshipwithfood/alcohol
Responsetoanyprevioustreatment
Anyrecentchangeinvision
Associationwithrecenttrauma
Anyrecentchangesinsleep,exercise,weight,ordiet
Stateofgeneralhealth
Changeinworkorlifestyle(disability)
Changeinmethodofbirthcontrol(women)
Possibleassociationwithenvironmentalfactors
Effectsofmenstrualcycleandexogenoushormones(women)

Theexaminationofanadultwithheadachecomplaintsshouldcoverthefollowingareas:

Obtainbloodpressureandpulse
Listenforbruitatneck,eyes,andheadforclinicalsignsofarteriovenousmalformation
Palpatethehead,neck,andshoulderregions
Checktemporalandneckarteries
Examinethespineandneckmuscles

Theneurologicexaminationshouldcovermentalstatustesting,cranialnerveexamination,funduscopyand
otoscopy,andsymmetryonmotor,reflex,cerebellar(coordination),andsensorytests.Gaitexaminationshould
includegettingupfromaseatedpositionwithoutanysupportandwalkingontiptoesandheels,tandemgait,and
Rombergtest.
Themajorityofpatientswithheadachecomplaintshaveacompletelynormalphysicalandneurologicexamination.
However,sometypesofprimaryheadachemaybeassociatedwithspecificabnormalities:
Withtensiontypeheadache,theremaybepericranialmuscletenderness.
Withmigraine,theremaybemanifestationsrelatedtosensitizationofprimarynociceptorsandcentral
trigeminovascularneurons,suchashyperalgesiaandallodynia.
Withhemicraniacontinuaoroneoftheothertrigeminalautonomiccephalalgias(clusterheadache,
paroxysmalhemicrania,andshortlastingunilateralneuralgiformheadacheattacks),theremaybeevidence
ofautonomicactivation.
Otherabnormalitiesonexaminationshouldraisesuspicionforasecondaryheadachedisorder.Likewise,danger
signs(ie,redflags)shouldpromptfurtherevaluation,asdiscussedinthesectionsbelow.
DangersignsPayingattentiontodangersignsisimportantsinceheadachesmaybethepresentingsymptom
ofaspaceoccupyingmassorvascularlesion,infection,metabolicdisturbance,orasystemicproblem.The
followingfeaturesinthehistorycanserveaswarningsignsofpossibleseriousunderlyingdisease[810].(See
"Evaluationoftheadultwithheadacheintheemergencydepartment".)
ThemnemonicSNOOPisareminderofthedangersigns("redflags")forthepresenceofseriousunderlying
disordersthatcancauseacuteorsubacuteheadache[11,12]:
Systemicsymptoms,illness,orcondition(eg,fever,weightloss,cancer,pregnancy,immunocompromised
stateincludingHIV)
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Neurologicsymptomsorabnormalsigns(eg,confusion,impairedalertnessorconsciousness,papilledema,
focalneurologicsymptomsorsigns,meningismus,orseizures)
Onsetisnew(particularlyforage>40years)orsudden(eg,"thunderclap")
Otherassociatedconditionsorfeatures(eg,headtrauma,illicitdruguse,ortoxicexposureheadache
awakensfromsleep,isworsewithValsalvamaneuvers,orisprecipitatedbycough,exertion,orsexual
activity)
Previousheadachehistorywithheadacheprogressionorchangeinattackfrequency,severity,orclinical
features
Anyofthesefindingsshouldpromptfurtherinvestigation,includingbrainimagingwithMRIorCT.(See'Indications
forimagingstudies'below.)
OtherfeaturessuggestingasecondaryheadachesourceOtherfeaturesthatsuggestaspecificsourceof
headachepainincludethefollowing:
Impairedvisionorseeinghalosaroundlightsuggeststhepresenceofglaucoma.Suspicionforsubacute
angleclosureglaucomashouldberaisedbyrelativelyshortduration(oftenlessthanonehour)unilateral
headachesthatdonotmeetcriteriaformigrainearisingafterage50[13].
Visualfielddefectssuggestthepresenceofalesionoftheopticpathway(eg,duetoapituitarymass).
Sudden,severe,unilateralvisionlosssuggeststhepresenceofopticneuritis.(See"Opticneuritis:
Pathophysiology,clinicalfeatures,anddiagnosis".)
Blurringofvisiononforwardbendingofthehead,headachesuponwakingearlyinthemorningthatimprove
withsittingup,anddoublevisionorlossofcoordinationandbalanceshouldraisethesuspicionofraised
intracranialpressurethisshouldalsobeconsideredinpatientswithchronic,daily,progressivelyworsening
headachesassociatedwithchronicnausea.
Inpatientswhopresentwithheadachethatisrelievedwithrecumbencyandexacerbatedwithupright
posture,thediagnosisofheadacheattributedtospontaneousintracranialhypotensionshouldbeconsidered.
AnadditionalmajorfeatureofthisheadachesyndromeisdiffusemeningealenhancementonbrainMRI.The
acceptedetiologyiscerebrospinalfluid(CSF)leakage,whichmayoccurinthecontextofruptureofan
arachnoidmembrane.(See"Spontaneousintracranialhypotension:Pathophysiology,clinicalfeatures,and
diagnosis".)
Thepresenceofnausea,vomiting,worseningofheadachewithchangesinbodyposition(particularly
bendingover),anabnormalneurologicexamination,and/orasignificantchangeinpriorheadachepattern
suggeststheheadachewascausedbyatumor.(See"Clinicalpresentationanddiagnosisofbraintumors".)
Intermittentheadacheswithhighbloodpressurearesuggestiveofpheochromocytoma.(See"Clinical
presentationanddiagnosisofpheochromocytoma".)
Morningheadacheisnonspecificandcanoccuraspartofaprimaryheadachesyndromeormaybe
secondarytoanumberofdisordersincludingsleepapnea,chronicobstructivepulmonarydisease,andthe
obesityhypoventilationsyndrome.(See"Clinicalpresentationanddiagnosisofobstructivesleepapneain
adults"and"Chronicobstructivepulmonarydisease:Definition,clinicalmanifestations,diagnosis,and
staging"and"Clinicalmanifestationsanddiagnosisofobesityhypoventilationsyndrome".)
DiagnosticinstrumentsAsmentionedabove,themostcommonheadachesyndromesfrequentlypresentwith
characteristicsymptoms(table1).However,theremaybeconsiderablesymptomoverlaponepopulationbased
surveyfoundthatlessthanonehalfofpatientswhocomplainedofheadachesthatmetcriteriaformigrainewere
properlydiagnosed[14].Migrainesymptomsmayalsooverlapwithothercausesofheadache.Asanexample,a
significantnumberofpatientswithmigrainemayhavenasalsymptomsthatsuggestsinusdisease[15]in
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addition,astudyofprimarycarepatientswithrecurrentsinusheadachefoundthat90percentexperiencedattacks
thatmettheInternationalHeadacheSociety(IHS)criteriaformigraine[16].(See'Sinussymptoms'below.)
Giventhesepitfalls,anumberofdiagnosticinstrumentshavebeenproposed,mainlytoassistwiththediagnosis
ofmigraine,themostcommonprimaryheadachesyndromeinpatientspresentingtoprimarycarephysicians.One
suchinstrument(IDMigraine)preselectseligiblesubjectsasthosewhohadtwoormoreheadachesinthe
previousthreemonthsandindicatedeitherthattheymightwanttospeakwithahealthcareprofessionalabouttheir
headachesorthattheyexperiencedaheadachethatlimitedtheirabilitytowork,study,orenjoylife[17].The
screenemploysthreequestions:
Duringthelastthreemonths,didyouhavethefollowingwithyourheadaches?
Youfeltnauseatedorsicktoyourstomach
Lightbotheredyou(alotmorethanwhenyoudon'thaveheadaches)
Yourheadacheslimitedyourabilitytowork,study,ordowhatyouneededtodoforatleastoneday
TheIDmigrainescreenispositiveifthepatientanswersyestotwoofthethreeitems.Inasystematicreviewof
13studiesthatinvolvedover5800patients,thepooledsensitivityandspecificityofIDmigrainewas0.84and
0.76,respectively[18].ApositiveIDmigraineincreasedthepretestprobabilityofmigrainefrom59to84percent,
whereasanegativeIDMigrainescorereducedtheprobabilityofmigrainefrom59to23percent.
Anothersimpleandvalidatedinstrument,thebriefheadachescreen,consistsofthreetosixquestions[19].One
versionincludesthefollowingfourquestions:

Howoftendoyougetsevereheadaches(ie,withouttreatmentitisdifficulttofunction)?
Howoftendoyougetother(milder)headaches?
Howoftendoyoutakeheadacherelieversorpainpills?
Hastherebeenanyrecentchangeinyourheadaches?

Inonestudy,thepresenceofepisodicdisablingheadachecorrectlyidentifiedmigrainein136of146patients(93
percent)withepisodicmigraine,and154of197patients(78percent)withchronicheadachewithmigraine,witha
specificityof63percent[19].Only6of343patients(2percent)withmigrainewerenotidentifiedbydisabling
headache.Thus,virtuallyanypatientwithsevereepisodicheadachescanbeconsideredtohavemigraine.
Questions2and3canbehelpfulforidentifyingpatientswithmedicationoveruse(eg,patientswhouse
symptomaticmedicationsmorethanthreedaysperweekand/orwhohavedailyheadaches).Question4is
particularlyhelpfulforidentifyingpatientswhomayhaveanimportantsecondarycauseofheadacheapatientwith
astablepatternofheadacheforsixmonthsisunlikelytohaveaseriousunderlyingcause.
IndicationsforimagingstudiesPatientswithanyofthedangersignsnotedaboveneedurgentbrainimaging
(see'Dangersigns'above).Ourapproachistoperformneuroimaginginthefollowingsituations[20]:

Focalneurologicsignsorsymptoms
Onsetofheadachewithexertion,cough,orsexualactivity
Orbitalbruit
Onsetofheadacheafterage40years
Recentsignificantchangeinthepattern,frequency,orseverityofheadaches
Progressiveworseningofheadachedespiteappropriatetherapy

MRIisthepreferredbrainimagingmodalityformostpatientsbecauseitismoresensitivethanCTscanfor
detectingedema,vascularlesions,andothertypesofintracranialpathology,particularlyintheposteriorfossa.
However,CTismorewidelyavailableandisthereforemoreusefulinurgentoremergencycaresituationswhen
thereisconcernforsubarachnoidhemorrhageasthecauseofthunderclapheadache.
Itmayalsobereasonabletoimageapatientpresentingwithnonmigrainousfeaturelessheadache,ie,bilateral
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nonthrobbingheadachewithoutnauseaandwithoutsensitivitytolight,sound,orsmell[21].Suchanapproach
wouldhaveanestimatedyieldof2percentfordetectingatreatablecause.
Intheremainingpatients,therearenorandomized,controlledtrialsthathelpdelineatewhenimagingisnecessary,
andnosuchtrialsarelikelytobeforthcomingasblindingandrandomizationwouldpresentethicalproblems.Asa
result,thedecisiontoscanornottoscaninheadacheislikelytoremainoneofclinicaljudgment[21].
Thevastmajorityofpatientswithoutdangersignsdonothaveasecondarycauseofheadache[22,23].Asan
example,inastudyof373patientswithchronicheadacheatatertiaryreferralcenter,allhadoneormoreofthe
followingcharacteristicsthatpromptedreferralforheadCTscanning:increasedseverityofsymptomsor
resistancetoappropriatedrugtherapy,changeincharacteristicsorpatternofheadache,orfamilyhistoryofan
intracranialstructurallesion[24].Onlyfourscans(1percent)showedsignificantlesions(twoosteomas,onelow
gradeglioma,andoneaneurysm)onlytheaneurysmwastreated.
Neuroimagingisusuallynotwarrantedforpatientswithmigraineandanormalneurologicexamination,althougha
lowerthresholdforimagingisreasonableforpatientswithatypicalmigrainefeaturesorinpatientswhodonotfulfill
thestrictdefinitionofmigraine[25].However,brainimagingfornootherreasonthanreassuranceissometimes
performedinclinicalpractice.Intheend,patientsareseekingareasonfortheproblem.Itisimportantthatthe
clinicianprovidethepatientwithaclearexplanationofboththediagnosisandthereasonforthebrainscan,
especiallyifthedecisionismadetoobtainimaginginsomeonesuspectedofhavingprimaryheadache[21].
IndicationsforlumbarpunctureLumbarpuncture(LP)forcerebrospinalfluidanalysisisurgentlyindicatedin
patientswithheadachewhenthereisclinicalsuspicionofsubarachnoidhemorrhageinthesettingofanegativeor
normalheadCTscan.Inaddition,LPisindicatedwhenthereisclinicalsuspicionofaninfectiousorinflammatory
etiologyofheadache.Theseissuesarediscussedelsewhere.(See"Clinicalmanifestationsanddiagnosisof
aneurysmalsubarachnoidhemorrhage",sectionon'Diagnosisofsubarachnoidhemorrhage'and"Lumbarpuncture:
Technique,indications,contraindications,andcomplicationsinadults",sectionon'Indications'.)
PATIENTSETTINGSDifferencesinpatientdemographics,comorbidities,andheadachefeaturescanguidethe
evaluationtohelpensureappropriatediagnosisandmanagement.
EmergencyTheevaluationoftheadultpresentingtotheemergencydepartmentwithheadacheisreviewedin
detailelsewhere(see"Evaluationoftheadultwithheadacheintheemergencydepartment").Themaingoalofthe
evaluationistodifferentiatetherelativelysmallnumberofpatientswithseriousorlifethreateningheadachesfrom
themajoritywithbenignprimaryheadaches(algorithm1andalgorithm2).
SuddenonsetSevereheadacheofsuddenonset(ie,thatreachesmaximalintensitywithinafewsecondsor
lessthanoneminuteaftertheonsetofpain)isknownasthunderclapheadachebecauseitsexplosiveand
unexpectednatureislikenedtoa"clapofthunder."Thunderclapheadacherequiresurgentevaluationassuch
headachesmaybeharbingersofsubarachnoidhemorrhageandotherpotentiallyominousetiologies(table4).
Theseincludecerebralvenousthrombosis,cervicalarterydissection,spontaneousintracranialhypotension,
pituitaryapoplexy,retroclivalhematoma,ischemicstroke,acutehypertensivecrisiswithreversibleposterior
leukoencephalopathysyndrome,"orgasmic"headacheassociatedwithsexualactivity,thirdventricularcolloid
cysts,bacterialandviralmeningitis,complicatedsinusitis,andreversiblecerebralvasoconstrictionsyndromes.
(See"Thunderclapheadache".)
Forallpatientswiththunderclapheadache,werecommendheadCTand,ifheadCTisnormal,lumbarpuncture
withmeasurementofopeningpressureandcerebrospinalfluidanalysistoexcludesubarachnoidhemorrhage.For
patientswiththunderclapheadachewhohavenondiagnosticheadCTandlumbarpuncture,imagingofthecerebral
circulationisnecessary.WesuggestobtainingbrainMRIandnoninvasiveneurovascularimagingsuchasMRor
CTangiography/venography.(See"Thunderclapheadache",sectionon'Diagnosticevaluation'.)
NeworrecentonsetheadacheTheabsenceofsimilarheadachesinthepastisanotherfindingthatsuggests
apossibleseriousdisorder.
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Newheadacheinpatientsolderthan40yearsmaysuggestunderlyingpathology
Newheadachetypeinapatientwithcancersuggestsmetastasis
NewheadachetypeinapatientwithLymediseasesuggestsmeningoencephalitis
NewheadachetypeinapatientwithHIVsuggestsanopportunisticinfectionortumor
Incontrast,patientswithmigraineusuallyhavehadsimilartypesofheadachesinthepast.
Braintumorisararecauseofheadachebutshouldbeconsideredinpatientspresentingwithfocalneurologic
signs.Itshouldalsobeconsideredwhennewonsetheadachesoccurinadultsolderthan50years.Apriorhistory
ofheadachedoesnotruleoutthepossibilityofbraintumor,andachangeinheadachepatternisadiagnostic"red
flag."Thefeaturesofbraintumorheadachearegenerallynonspecificandvarywidelywithtumorlocation,size,
andrateofgrowth.Theheadacheisusuallybilateral,butcanbeonthesideofthetumor.Braintumorheadache
oftenresemblestensiontypeheadache,butmayresemblemigraineoravarietyofotherheadachetypes.(See
"Braintumorheadache".)
ChronicheadacheChronicdailyheadacheisnotaspecificheadachetype,butasyndromethatencompasses
anumberofprimaryandsecondaryheadaches.Theterm"chronic"referseithertothefrequencyofheadachesor
tothedurationofthedisease,dependinguponthespecificheadachetype.(See"Overviewofchronicdaily
headache".)
Withheadachesubtypesoflongduration(ie,fourhoursormore),"chronic"indicatesaheadachefrequencyof15
ormoredaysamonthforlongerthanthreemonthsintheabsenceoforganicpathology.Theseheadachesubtypes
are:
Chronicmigraineheadache(see"Chronicmigraine")
Chronictensiontypeheadache(see"Tensiontypeheadacheinadults:Pathophysiology,clinicalfeatures,
anddiagnosis")
Medicationoveruseheadache,whichistypicallyprecededbyanepisodicheadachedisorder(usually
migraineortensiontypeheadache)thathasbeentreatedwithfrequentandexcessiveamountsofacute
symptomaticmedications(see"Medicationoveruseheadache:Etiology,clinicalfeatures,anddiagnosis")
Hemicraniacontinua,astrictlyunilateral,continuousheadachewithsuperimposedexacerbationsof
moderatetosevereintensityaccompaniedbyautonomicfeaturesandsometimesbymigrainoussymptoms
(see"Hemicraniacontinua")
Newdailypersistentheadache,characterizedbyheadachethatbeginsratherabruptlyandisdailyand
unremittingfromonsetorwithinthreedaysofonsetatmost,typicallyinindividualswithoutapriorheadache
history(see"Newdailypersistentheadache")
Withheadachesubtypesofshorterduration(ie,lessthanfourhours),"chronic"referstoaprolongeddurationof
theconditionitselfwithoutremission.Theheadachesubtypesinthiscategoryarethefollowing:
Chronicclusterheadache(see"Clusterheadache:Epidemiology,clinicalfeatures,anddiagnosis")
Chronicparoxysmalhemicrania,characterizedbyunilateral,brief,severeattacksofpainassociatedwith
cranialautonomicfeaturesthatrecurseveraltimesperdaywithindividualheadacheattacksthatusuallylast
2to30minutes(see"Paroxysmalhemicrania:Clinicalfeaturesanddiagnosis")
Shortlastingunilateralneuralgiformheadacheattacks,characterizedbysuddenbriefattacksofsevere
unilateralheadpaininorbital,periorbital,ortemporalregions,accompaniedbyipsilateralcranialautonomic
symptoms(see"Shortlastingunilateralneuralgiformheadacheattacks:Clinicalfeaturesanddiagnosis")
Hypnicheadache,alsoknownas"alarmclockheadache,"whichoccursalmostexclusivelyaftertheageof
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50yearsandischaracterizedbyepisodesofdullheadpain,oftenbilateral,thatawakenthesuffererfrom
sleep(see"Hypnicheadache")
Primarystabbingheadache,characterizedbysuddenbriefattacksofsharp,jabbingheadpaininorbital,peri
orbital,ortemporalregions(see"Primarystabbingheadache")
OlderpatientsOlderpatientsareatincreasedriskforsecondarytypesofheadache(eg,giantcellarteritis,
trigeminalneuralgia,subduralhematoma,acuteherpeszosterandpostherpeticneuralgia,andbraintumors)and
sometypesofprimaryheadache(hypnicheadache,coughheadache,andmigraineaccompaniments)[26].
Giantcell(temporal)arteritisisachronicvasculitisoflargeandmediumsizedvessels.Thegreatestrisk
factorfordevelopinggiantcellarteritisisaging.Thediseaseseldomoccursbeforeage50years,andits
incidencerisessteadilythereafter.Anewtypeofheadacheoccursintwothirdsofaffectedindividuals.The
headpaintendstobelocatedoverthetemporalareasbutcanbefrontaloroccipitalinlocation.The
headachesmaybemildorsevere.Othercommonsymptomsincludefever,fatigue,weightloss,jaw
claudication,visualsymptoms,particularlytransientmonocularvisuallossanddiplopia,andsymptomsof
polymyalgiarheumatica.(See"Clinicalmanifestationsofgiantcell(temporal)arteritis".)
Trigeminalneuralgiaisdefinedclinicallybysudden,usuallyunilateral,severe,brief,stabbingorlancinating,
recurrentepisodesofpaininthedistributionofoneormorebranchesofthefifthcranial(trigeminal)nerve.
Theincidenceincreasesgraduallywithagemostidiopathiccasesbeginafterage50years.(See"Trigeminal
neuralgia".)
Chronicsubduralhematomamaypresentwiththeinsidiousonsetofheadaches,lightheadedness,cognitive
impairment,apathy,somnolence,andoccasionallyseizures.(See"Subduralhematomainadults:Etiology,
clinicalfeatures,anddiagnosis".)
Acuteherpeszosterandpostherpeticneuralgiaofteninvolvecervicalandtrigeminalnerves.Painisthemost
commonsymptomofzosterandapproximately75percentofpatientshaveprodromalpaininthedermatome
wheretherashsubsequentlyappears.Themajorriskfactorsforpostherpeticneuralgiaareolderage,greater
acutepain,andgreaterrashseverity.(See"Clinicalmanifestationsofvaricellazostervirusinfection:Herpes
zoster"and"Postherpeticneuralgia".)
Braintumorshouldbeconsideredasapossiblecauseofnewonsetheadachesinadultsoverage50years,
asdiscussedabove.(See'Neworrecentonsetheadache'aboveand"Braintumorheadache".)
Hypnicheadache,alsoknownas"alarmclockheadache,"occursalmostexclusivelyaftertheageof50
yearsandischaracterizedbyepisodesofdullheadpain,oftenbilateral,thatawakenthesuffererfromsleep.
(See"Hypnicheadache".)
Primarycoughheadachemostoftenaffectspeopleolderthanage40yearsandisprovokedbycoughingor
strainingintheabsenceofanyintracranialdisorder.(See"Primarycoughheadache".)
Latelifemigraineaccompanimentsaresymptomsrelatedtotheonsetaftertheageof40yearsofmigraine
aurawithoutheadache[27].Themostcommonsymptomsarevisualauras,followedbysensoryauras
(paresthesia),speechdisturbances,andmotorauras(weaknessorparalysis).Themostcommon
presentationisgradualevolutionofaurasymptomswithspreadoftransientneurologicdeficitsoverseveral
minutesandserialprogressionfromonesymptomtoanother.
PregnancyNewheadacheorchangeinheadacheduringpregnancymaybeduetomigraineortensiontype
headaches,butmanyotherconditionscanpresentwithheadacheatthistime,particularlypreeclampsia,post
duralpunctureheadache,andcerebralvenousthrombosis.Amongpregnantwomenwiththeonsetofnewor
atypicalheadache,approximatelyonethirdhavemigraine,onethirdhavepreeclampsia/eclampsiarelated
headache,andtheremainingonethirdhaveavarietyofothercausesofheadache.
Preeclampsiamustberuledinoroutineverypregnantwomanover20weeksofgestationwithheadache.(See
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"Headacheinpregnantandpostpartumwomen".)
FeverFeverassociatedwithheadachemaybecausedbyintracranial,systemic,orlocalinfection,aswellas
otheretiologies(table5).
ImmunocompromisedNewheadachetypeinapatientwithHIVorotherimmunocompromisedstatesuggests
anopportunisticinfectionorneoplasmasthecause.
TraumaticbraininjuryHeadacheisvariablyestimatedasoccurringin25to78percentofpersonsfollowing
mildtraumaticbraininjury.Paradoxically,headacheprevalence,duration,andseverityisgreaterinthosewithmild
headinjurycomparedwiththosewithmoreseveretrauma.Mostoften,headachefollowingheadtraumacanbe
classifiedsimilarlytonontraumaticheadachesmigraineandtensiontypeheadachepredominate.(See
"Postconcussionsyndrome",sectionon'Headaches'.)
SinussymptomsAlthoughsinusheadacheiscommonlydiagnosedbyphysiciansandselfdiagnosedby
patients,acuteorchronicsinusitisappearstobeanuncommoncauseofrecurrentheadaches[24].
Autonomicfeaturescharacteristicallyoccurintrigeminalautonomiccephalgiassuchasclusterheadachesandare
alsocommonwithmigraineheadache.Thesesymptomsmayincludenasalcongestion,rhinorrhea,tearing,color
andtemperaturechange,andchangesinpupilsize.(See"Pathophysiology,clinicalmanifestations,anddiagnosis
ofmigraineinadults".)
Theprominenceofsinussymptomsoftenleadstothemisdiagnosisof"sinusheadache"inpatientswhomeet
diagnosticcriteriaformigraineor,lessoften,tensiontypeheadache.Thispointisillustratedbyanobservational
studythatenrolled2991patientswithahistoryofphysicianorselfdiagnosedsinusheadacheandnoprevious
historyofmigraine88percentofthesepatientsfulfilledcriteriaformigraineormigrainousheadache,and8percent
fulfilledcriteriafortensiontypeheadache[28].Inthepatientswithmigraineormigrainousheadache,sinuspain,
pressure,andcongestioncommonlyoccurredinassociationwithtypicalmigrainefeaturessuchaspulsinghead
painandsensitivitytoactivity,light,andsound(figure1).
Painrelatedpurelytosinusconditionsmayhavesomefeaturesthataidindistinguishingitfrommigraine[29,30].
Sinusrelatedpainorheadacheistypicallydescribedasapressurelikeordullsensationthatisusuallybilateral
andperiorbital.However,itcanbeunilateralwithdeviatedseptum,middleorinferiorturbinatehypertrophy,or
unilateralsinusdisease.Inaddition,sinusrelatedpainistypicallyassociatedwithnasalobstructionorcongestion,
lastsfordaysatatime,andisusuallynotassociatedwithnausea,vomiting,photophobia,orsonophobia.(See
"Acutesinusitisandrhinosinusitisinadults:Clinicalmanifestationsanddiagnosis".)
Theseverity,extent,andlocationofsinusrelatedpaindonotcorrelatewiththeextentorlocationofmucosal
diseaseasrevealedbyimaging[30].
Ingeneral,thefollowingprinciplesapplytotherelationshipofrhinosinusitisandheadache[29,31,32]:
Astablepatternofrecurrentheadachesthatinterferewithdailyfunctionismostlikelymigraine.
Recurrentselflimitedheadachesassociatedwithrhinogenicsymptomsaremostlikelymigraine.
Prominentrhinogenicsymptomswithheadacheasoneofseveralsymptomsshouldbeevaluatedcarefully
forotolaryngologicconditions.
Headacheassociatedwithfeverandpurulentnasaldischargeislikelyrhinogenicinorigin.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
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withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Headache(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Headachecausesanddiagnosisinadults(Beyondthe
Basics)"and"Patientinformation:Headachetreatmentinadults(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Whileepisodictensiontypeheadacheisthemostfrequentheadachetypeinpopulationbasedstudies,
migraineisthemostcommondiagnosisinpatientspresentingtoprimarycarephysicianswithheadache.
Clinicianscaneasilybecomefamiliarwiththemostcommonprimaryheadachedisordersandhowto
distinguishthem(table1).(See'Epidemiologyandclassification'above.)
Usingthepatienthistoryastheprimarydiagnostictool,theinitialheadacheevaluationshoulddetermine
whetherthereisapotentiallydangeroussecondarycauseofheadacheorwhethertheheadacheisdueto
oneofthecommontypesofprimaryheadache.(See'Evaluation'above.)
ThemnemonicSNOOPisareminderofthedangersigns("redflags")forthepresenceofseriousunderlying
disordersthatcancauseacuteorsubacuteheadache:
Systemicsymptoms,illness,orcondition(eg,fever,weightloss,cancer,pregnancy,
immunocompromisedstateincludingHIV)
Neurologicsymptomsorabnormalsigns(eg,confusion,impairedalertnessorconsciousness,
papilledema,focalneurologicsymptomsorsigns,meningismus,orseizures)
Onsetisnew(particularlyforage>40years)orsudden(eg,"thunderclap")
Otherassociatedconditionsorfeatures(eg,headtrauma,illicitdruguse,ortoxicexposureheadache
awakensfromsleep,isworsewithValsalvamaneuvers,orisprecipitatedbycough,exertion,orsexual
activity)
Previousheadachehistorywithheadacheprogressionorchangeinattackfrequency,severity,or
clinicalfeatures
Anyofthesefindingsshouldpromptfurtherinvestigation,includingbrainimagingwithMRIorCT.(See
'Dangersigns'aboveand'Indicationsforimagingstudies'above.)
Differencesinpatientdemographics,comorbidities,andheadachefeaturescanguidetheevaluationtohelp
ensureappropriatediagnosisandmanagement.(See'Patientsettings'above.)
Thunderclapheadachemaybetheharbingerofsubarachnoidhemorrhageandotherpotentiallyominous
etiologies(table4)(see'Suddenonset'above)
Theabsenceofsimilarheadachesinthepastisanotherfindingthatsuggestsapossibleserious
disorder(see'Neworrecentonsetheadache'above)
Chronicdailyheadacheisasyndromethatencompassesanumberofprimaryandsecondary
headaches(see'Chronicheadache'above)
Olderpatientsareatincreasedriskforsecondarytypesofheadache(eg,giantcellarteritis,trigeminal
neuralgia,subduralhematoma,acuteherpeszosterandpostherpeticneuralgia,andbraintumors)and
sometypesofprimaryheadache(hypnicheadache,coughheadache,andmigraineaccompaniments)
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(see'Olderpatients'above)
Preeclampsiamustberuledinoroutineverypregnantwomanover20weeksofgestationwith
headache(see'Pregnancy'above)
Feverassociatedwithheadachemaybecausedbyintracranial,systemic,orlocalinfection,aswellas
otheretiologies(table5)(see'Fever'above)
Headacheisafrequentsequelaeofmildtraumaticbraininjury(see'Traumaticbraininjury'above)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.BigalME,BordiniCA,SpecialiJG.EtiologyanddistributionofheadachesintwoBrazilianprimarycare
units.Headache200040:241.
2.CadyRK,SchreiberCP.Sinusheadacheormigraine?Considerationsinmakingadifferentialdiagnosis.
Neurology200258:S10.
3.MehleME.Whatdoweknowaboutrhinogenicheadache?Theotolaryngologistschallenge.OtolaryngolClin
NorthAm201447:255.
4.ErossE,DodickD,ErossM.TheSinus,AllergyandMigraineStudy(SAMS).Headache200747:213.
5.GilGouveiaR,MartinsIP.Headachesassociatedwithrefractiveerrors:mythorreality?Headache2002
42:256.
6.BuringJE,HebertP,RomeroJ,etal.MigraineandsubsequentriskofstrokeinthePhysicians'Health
Study.ArchNeurol199552:129.
7.HagenK,StovnerLJ,VattenL,etal.Bloodpressureandriskofheadache:aprospectivestudyof22685
adultsinNorway.JNeurolNeurosurgPsychiatry200272:463.
8.EdmeadsJ.Emergencymanagementofheadache.Headache198828:675.
9.LiptonRB,BigalME,SteinerTJ,etal.Classificationofprimaryheadaches.Neurology200463:427.
10.LynchKM,BrettF.Headachesthatkill:aretrospectivestudyofincidence,etiologyandclinicalfeaturesin
casesofsuddendeath.Cephalalgia201232:972.
11.DodickD.Headacheasasymptomofominousdisease.Whatarethewarningsignals?PostgradMed1997
101:46.
12.VenkatesanA.Case13:amanwithprogressiveheadacheandconfusion.MedGenMed20068:19.
13.ShindlerKS,SankarPS,VolpeNJ,PiltzSeymourJR.Intermittentheadachesasthepresentingsignof
subacuteangleclosureglaucoma.Neurology200565:757.
14.LiptonRB,DiamondS,ReedM,etal.Migrainediagnosisandtreatment:resultsfromtheAmericanMigraine
StudyII.Headache200141:638.
15.BarbantiP,FabbriniG,PesareM,etal.Unilateralcranialautonomicsymptomsinmigraine.Cephalalgia
200222:256.
16.CadyRK,SchreiberCP.Sinusheadache:aclinicalconundrum.OtolaryngolClinNorthAm200437:267.
17.RapoportAM,BigalME.IDmigraine.NeurolSci200425Suppl3:S258.
18.CousinsG,HijazzeS,VandeLaarFA,FaheyT.DiagnosticaccuracyoftheIDMigraine:asystematic
reviewandmetaanalysis.Headache201151:1140.
19.MaizelsM,BurchetteR.Rapidandsensitiveparadigmforscreeningpatientswithheadacheinprimarycare
settings.Headache200343:441.
20.KumarKL,CooneyTG.Headaches.MedClinNorthAm199579:261.
21.GoadsbyPJ.Toscanornottoscaninheadache.BMJ2004329:469.
22.TsushimaY,EndoK.MRimagingintheevaluationofchronicorrecurrentheadache.Radiology2005
235:575.
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23.YouJJ,GladstoneJ,SymonsS,etal.Patternsofcareandoutcomesaftercomputedtomographyscansfor
headache.AmJMed2011124:58.
24.DumasMD,PexmanJH,KreeftJH.Computedtomographyevaluationofpatientswithchronicheadache.
CMAJ1994151:1447.
25.SilbersteinSD,RosenbergJ.Multispecialtyconsensusondiagnosisandtreatmentofheadache.Neurology
200054:1553.
26.HaleN,PaauwDS.Diagnosisandtreatmentofheadacheintheambulatorycaresetting:areviewofclassic
presentationsandnewconsiderationsindiagnosisandmanagement.MedClinNorthAm201498:505.
27.VongvaivanichK,LertakyamaneeP,SilbersteinSD,DodickDW.Latelifemigraineaccompaniments:A
narrativereview.Cephalalgia201535:894.
28.SchreiberCP,HutchinsonS,WebsterCJ,etal.Prevalenceofmigraineinpatientswithahistoryofself
reportedorphysiciandiagnosed"sinus"headache.ArchInternMed2004164:1769.
29.CadyRK,DodickDW,LevineHL,etal.Sinusheadache:aneurology,otolaryngology,allergy,andprimary
careconsensusondiagnosisandtreatment.MayoClinProc200580:908.
30.TarabichiM.Characteristicsofsinusrelatedpain.OtolaryngolHeadNeckSurg2000122:842.
31.LevineHL,SetzenM,CadyRK,etal.Anotolaryngology,neurology,allergy,andprimarycareconsensuson
diagnosisandtreatmentofsinusheadache.OtolaryngolHeadNeckSurg2006134:516.
32.MarmuraMJ,SilbersteinSD.Headachescausedbynasalandparanasalsinusdisease.NeurolClin2014
32:507.
Topic3349Version17.0

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GRAPHICS
Characteristicsofmigraine,tensiontype,andclusterheadache
syndromes
Symptom

Migraine

Tension
type

Cluster

Location

Unilateralin60to70percent
bifrontalorglobalin30percent

Bilateral

Alwaysunilateral,usuallybegins
aroundtheeyeortemple

Characteristics

Gradualinonset,crescendo
patternpulsatingmoderate
orsevereintensityaggravated
byroutinephysicalactivity

Pressureor
tightness
which
waxesand
wanes

Painbeginsquickly,reachesa
crescendowithinminutespain
isdeep,continuous,excruciating,
andexplosiveinquality

Patient
appearance

Patientpreferstorestina
dark,quietroom

Patientmay
remain
activeor
mayneed

Patientremainsactive

torest
Duration

4to72hours

Variable

30minutesto3hours

Associated
symptoms

Nausea,vomiting,
photophobia,phonophobia
mayhaveaura(usuallyvisual,
butcaninvolveothersensesor
causespeechormotordeficits)

None

Ipsilaterallacrimationand
rednessoftheeyestuffynose
rhinorrheapallorsweating
Horner'ssyndromefocal
neurologicsymptomsrare
sensitivitytoalcohol

Graphic68064Version5.0

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Headachetriggers
Diet

Stress

Alcohol

Letdownperiods

Chocolate

Timesofintenseactivity

Agedcheeses

Lossorchange(death,separation,divorce,
jobchange)

Monosodiumglutamate
Aspartame
Caffeine
Nuts
Nitrites,nitrates

Hormones
Menses
Ovulation
Hormonereplacement(progesterone)

Sensorystimuli
Stronglight
Flickeringlights
Odors

Moving
Crisis

Changesofenvironmentorhabits
Weather
Travel(crossingtimezones)
Seasons
Altitude
Schedulechanges
Sleepingpatterns
Dieting
Skippingmeals
Irregularphysicalactivity

Sounds,noise
Graphic57424Version4.0

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Clinicalfeaturesofthetrigeminalautonomiccephalalgias

Sex
(female:male)

Cluster
headache
1:3to1:7

Paroxysmal
hemicrania
1:1to2.7:1

SUNCTand
SUNA
1:1.5

Pain
Type

Hemicrania
continua
2:1

Stabbing,boring

Sharp,stabbing,
throbbing

Burning,
stabbing,sharp

Throbbing,sharp,
pressure,dull,
burning,aching,
orstabbing

Severity

Excruciating

Excruciating

Severeto
excruciating

Mildtosevere

Site

Orbit,temple

Orbit,temple

Periorbital

Orbital,frontal,
temporalless
oftenoccipital

Attack
frequency

1everyotherday
to8perday

1to40aday(>5
perdayformore
thanhalfthe
time)

1to200perday

Continuouspain
with
exacerbations

Durationof
attack

15to180
minutes

2to30minutes

1to600seconds

Monthstoyears

Autonomic

Yes

Yes

Yes(prominent

Yes

features

conjunctival
injectionand
lacrimationwith
SUNCT)

Restlessness
and/or
agitation

Yes

Yes

Frequent

Yes

Migrainous
features
(nausea,
photophobia,or
phonophobia)

Yes

Yes

Rare

Frequent

Alcoholtrigger

Yes

Occasional

No

Occasional

Cutaneous
triggers

No

Rare

Yes

No

Indomethacin
effect

None

Absolute

None

Absolute

Abortive
treatment

Sumatriptan
injectionornasal
spray

Nil

Lidocaine
intravenous
infusion

Nil

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Oxygen
Prophylactic
treatment

Verapamil

Indomethacin

Lamotrigine

Methysergide

Topiramate

Lithium

Gabapentin

Indomethacin

SUNCT:shortlastingunilateralneuralgiformpainwithconjunctivalinjectionandtearingSUNA:short
lastingunilateralneuralgiformheadacheattackswithcranialautonomicsymptoms.
Graphic65541Version9.0

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ManagementofheadacheintheemergencydepartmentI

Graphic71604Version3.0

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Managementofheadacheintheemergencydepartment
II

CNS:centralnervoussystemCSF:cerebrospinalfluidCT:computedtomographyscan
LP:lumbarpunctureRBC:redbloodcellWBC:whitebloodcell.
Graphic51917Version4.0

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Etiologiesofthunderclapheadache
Subarachnoidhemorrhage
Sentinelheadache
Reversiblecerebralvasoconstrictionsyndromes
Cerebralvenousthrombosis
Cervicalarterydissection
Spontaneousintracranialhypotension
Pituitaryapoplexy
Orgasmicheadacheassociatedwithsexualactivity
Retroclivalhematoma
Ischemicstroke
Acutehypertensivecrisis
Colloidcystofthethirdventricle
Infections(eg,acutecomplicatedsinusitis)
Primarythunderclapheadache
Graphic81710Version5.0

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Differentialdiagnosisofheadachewithfever
Intracranialinfection
Meningitis
Bacterial
Fungal
Viral
Lymphocytic

Encephalitis
Brainabscess
Subduralempyema

Systemicinfection
Bacterialinfection
Viralinfection
HIV/AIDS
Othersystemicinfection

Othercauses
Familialhemiplegicmigraine
Pituitaryapoplexy
Rhinosinusitis
Subarachnoidhemorrhage
Malignancyofcentralnervoussystem
Graphic80966Version3.0

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Sinussymptomsarecommoninpatientswith
migraine

Inthisobservationalstudyofpatientswithahistoryofsinus
headacheandnoprevioushistoryofmigraine,sinuspain,pressure,
andcongestioncommonlyoccurredinassociationwithtypical
migrainefeaturessuchaspulsingheadpainandsensitivityto
activity,light,andsound.
Reproducedwithpermissionfrom:SchreiberCP,HutchinsonS,WebsterCJ,et
al.Prevalenceofmigraineinpatientswithahistoryofselfreportedor
physiciandiagnosed"sinus"headache.ArchInternMed2004164:1769.
Copyright2004AmericanMedicalAssociation.Allrightsreserved.
Graphic66523Version15.0

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ContributorDisclosures
ZahidHBajwa,MDGrant/ResearchSupport:Amgen[Chronicmigraine(Observationalstudy)].
Consultant/AdvisoryBoards:Depomed[Chronicpain(Tapentadol)].Speaker'sBureau:Teva[Migraine
(Sumatriptaniontophoretictransdermalsystem)]Depomed[Migraine(Diclofenac)]AstraZeneca[Chronicpain
(Naloxegol)].RJoshuaWootton,MDiv,PhDNothingtodisclose.JerryWSwanson,MD,MHPENothingto
disclose.JohnFDashe,MD,PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovided
tosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDate
standardsofevidence.
Conflictofinterestpolicy

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