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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
SciHub
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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.
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ManagementofheadacheintheemergencydepartmentI
Graphic71604Version3.0
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Managementofheadacheintheemergencydepartment
II
CNS:centralnervoussystemCSF:cerebrospinalfluidCT:computedtomographyscan
LP:lumbarpunctureRBC:redbloodcellWBC:whitebloodcell.
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Etiologiesofthunderclapheadache
Subarachnoidhemorrhage
Sentinelheadache
Reversiblecerebralvasoconstrictionsyndromes
Cerebralvenousthrombosis
Cervicalarterydissection
Spontaneousintracranialhypotension
Pituitaryapoplexy
Orgasmicheadacheassociatedwithsexualactivity
Retroclivalhematoma
Ischemicstroke
Acutehypertensivecrisis
Colloidcystofthethirdventricle
Infections(eg,acutecomplicatedsinusitis)
Primarythunderclapheadache
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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.
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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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