Headache Signs and Symptoms

• Very common problem presenting to primary care clinicians and neurologists
  • Almost half of adults worldwide experiences headache and 30% of them have migraine headache
  • Commonly affects individuals 25-55 years old, with an estimated lifetime prevalence between 0.2%-60%
  • Most common primary headache is tension-type headache while cluster headache is relatively common affecting about 1 in 1,000 adults worldwide

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