creation date: 2026-02-09 18:44
tags: Workups
Headache
Background
Headaches are a common medical complaint. As per its name, headaches consist of pain to any part of the head. The exact characteristics of the pain varies based on the type of headache.
Pathophysiology
The brain parenchyma does not have cociceptors and thus headaches are a result of pain originating from the surrounding structures such as:
- Blood vessels
- Meninges
- Muscle fibres
- Facial structures
- Cranial or spinal nerves
The may be due to stretching, dilation, constriction, or nociceptor stimulation of those structures but the pathophysiology of primary headaches are not fully understood. The pathophysiology of secondary headaches depends on the underlying process.
Differential Diagnosis
Primary headaches
- Migraine (episodic, usually unilateral, throbbing/pulsatile)
- Tension-type headache (mild-to-moderate, bilateral, nonthrobbing headache)
- Cluster headache (unilateral, severe headache with ipsilateral cranial autonomic symptoms)
Secondary headaches
- Head and/or neck trauma
- Cerebrovascular disease or vasculopathy
- Intracerebral hemorrhage
- Subarachnoid hemorrhage
- Subdural hematoma
- Cerebral venous thrombosis
- Reversible cerebral vasoconstriction syndrome
- Cerebral and cervical artery dissection
- Intracranial mass lesion or other causes of abnormal intracranial pressure
- Brain tumour
- Intracranial hypertension
- Medications or medication withdrawal
- Carbon monoxide poisoning
- Infection
- Metabolic disorders and elevated blood pressure
- Painful conditions of the head and neck (eg. open-angle glaucoma)
- Psychiatric conditions
Initial Evaluation
History
A systematic history of the characteristics of the pain should be performed (OPQRST). Additionally, include:
- Prodrome or presence of aura
- Exacerbation/relief with position changes, activity, food/alcohol
- Sources of stress
Physical Exam
Exam should include:
- Blood pressure and pulse
- Examination of head, neck, temporomanibular, and shoulder muscles
- Auscultation of temporal and neck arteries for bruits
A complete neurological examination should be performed.
Features of Evaluation
Low risk features
Patients with these features do not require further workup:
- Age ≤50
- Features typical of primary headaches
- History of similar headaches
- No abnormal neurological findings
- No concerning changes in usual headache pattern
- No high-risk comorbid conditions
- No new or concerning findings on history or examination
High risk features
The signs that point towards concerning etiology of headaches are described by the mnemonic SNNOOP10:
- Systemic symptoms (eg. fever)
- Neoplasm history
- Neurologic deficit (incl. decreased conciousness)
- Onset is sudden or abrupt
- Older age (>50)
- Pattern change or recent onset of new headache
- Positional headache
- Precipitated by sneezing, coughing, or exercise
- Papilledema
- Progressive headache and atypical presentations
- Pregnancy or puerperium
- Painful eyes with autonomic features
- Post-traumatic onset of headache
- Pathology of the immune system of immunosuppressive therapy
- Painkiller overuse
Investigations
In cases of suspicious headache, imaging is indicated. This typically consist of CT scan. In some circumstances, lumbar puncture or further imaging (MRI) may be indicated.