headache
HEADACHE
Headache is a very common problem presenting to primary care physicians and neurologists.
Most headaches are diagnosed based on the history & physical exam w/ no imaging or laboratory examination necessary.
Other types of headaches such as secondary headaches may require further evaluation & referral to a specialist.

Introduction

Headache

  • Very common problem presenting to primary care clinicians and neurologists
    • Almost half of adults worldwide experiences headache and 30% of them have migraine headache
    • Most common primary headache is tension-type headache while cluster headache is relatively common affecting about 1 in 1000 adults worldwide

Red Flag Signs and Symptoms

Further evaluation and/or referral is needed 

  • Worsening headache
  • Headache with fever and neck stiffness
  • Thunderclap headache
    • Sudden-onset of severe headache reaching maximum intensity within seconds to minutes
    • First or worst headache of the patient’s life (eg possible subarachnoid hemorrhage)
  • New-onset headache with:
    • Signs of systemic illness
    • Compromised immunity (eg caused by human immunodeficiency virus or immunosuppressive drug)
    • Age <20 years old and a history of malignancy
    • Age >50 years old with symptoms suggestive of temporal arteritis
    • Elderly patient with subacute cognitive change (eg possible subacute or chronic subdural hematoma)
    • History of malignancy known to metastasize to the brain
    • Vomiting without other obvious cause
    • Lyme disease
  • New-onset of severe headache in pregnancy or postpartum
  • Focal neurologic signs (not typical aura)
  • New-onset neurological deficit or cognitive dysfunction
  • Change in personality
  • Impaired level of consciousness
  • Recent head trauma (within the past 3 months)
  • Headache triggered by cough, sneeze, or valsalva
  • Headache triggered by exercise, exertion, or sexual intercourse
  • Rapid onset with strenuous exercise
  • Orthostatic headache
  • Symptoms suggestive of giant cell arteritis
  • Papilledema with altered level of consciousness and/or focal signs
  • Papilledema in an alert patient without focal neurological signs (eg possible pseudotumor cerebri)
  • Symptoms and signs of acute narrow-angle glaucoma
    • Eg non-reactive mid-dilated pupil, acutely inflamed eye, and visual disturbance with pain and nausea
  • Substantial change in the characteristics of the headache
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