Some Characteristics of Headache Disorders by Cause
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Primary headache disorders† | ||
Multiple unilateral orbitotemporal attacks, often at the same time of day Deep, severe, lasting 30–180 minutes Often with lacrimation, rhinorrhea, facial flushing, or Horner syndrome; restlessness | Clinical examination alone | |
Unilateral or bilateral and pulsating, lasting 4–72 hours Occasionally with aura Usually nausea, photophobia, sonophobia, or osmophobia Worse with activity, preference to lie in the dark, resolution with sleep | Clinical examination alone | |
Frequent or continuous, mild, bilateral, and viselike occipital or frontal pain that spreads to entire head Worse at end of day | Clinical examination alone | |
Secondary headache | ||
Unilateral frontal or orbital Halos around lights, decreased visual acuity, conjunctival injection, vomiting | Tonometry | |
Light-headedness, anorexia, nausea, vomiting, fatigue, irritability, difficulty sleeping In patients who have recently gone to a high altitude (including flying ≥ 6 hours in an airplane) | Clinical examination alone | |
Carbon monoxide poisoning | Often exposure to incompletely combusted hydrocarbons (eg, house fires, improperly vented automobiles, gas heaters, furnaces, hot water heaters, wood- or charcoal-burning stoves, kerosene heaters) | Carboxyhemoglobin level |
Cerebral venous sinus thrombosis | Symptoms similar to those of idiopathic intracranial hypertension but may begin suddenly | Neuroimaging (preferably MRI with magnetic resonance venography) |
Cervicogenic headache | Pain in neck area | Clinical examination alone |
Dental infections (in upper teeth) | Pain usually felt over the face, mostly unilateral, and worsened by chewing. Toothache | Dental examination |
Fever, altered mental status, seizures, focal neurologic deficits | MRI, CSF analysis | |
Age > 50 Unilateral throbbing pain, pain when combing hair, visual disturbances, jaw claudication, fever, weight loss, sweats, temporal artery tenderness, proximal myalgias | ESR, temporal artery biopsy, usually neuroimaging | |
Hypertensive headache | Associated with sudden severe rise of BP | Clinical evaluation |
Migraine-like headache, diplopia, pulsatile tinnitus, loss of peripheral vision, papilledema Usually gradual onset | Neuroimaging (preferably MRI with magnetic resonance venography), followed by measurement of CSF opening pressure and cell count culture and analysis | |
Sudden onset Vomiting, focal neurologic deficits, altered mental status | Neuroimaging | |
Chronic headache (usually chronic migraine) with variable location and intensity Occurs frequently and can be daily Often present on awakening Typically develops after overuse of analgesics taken for an episodic headache disorder | Clinical examination alone | |
Fever, meningismus, altered mental status | CSF analysis, often preceded by CT | |
Postcoital headache | Headache after orgasm | Clinical examination alone |
Intense headaches, often with meningismus and/or vomiting Worsened by sitting or standing and alleviated only by lying completely flat | For post-lumbar headache, clinical evaluation For other low-pressure headaches (eg, CSF leaks), sometimes MRI with gadolinium | |
Posttraumatic headache (usually a migraine or tension-type headache) | Similar to migraine or tension-type headache with neck pain | Clinical examination alone |
Positional facial or tooth pain, fever, purulent rhinorrhea | Clinical evaluation, sometimes CT | |
Peak intensity a few seconds after headache onset (thunderclap headache) Vomiting, syncope, obtundation, meningismus | Neuroimaging, followed by CSF analysis if it is not contraindicated and imaging is not diagnostic | |
Subdural hematoma (chronic) | Sleepiness, altered mental status, hemiparesis, loss of spontaneous retinal venous pulsations, papilledema | Neuroimaging |
Trigeminal neuralgia | Repeated short, lancinating severe pain on one side of the lower face | Clinical examination alone |
Tumor or mass | Eventually altered mental status, seizures, vomiting, diplopia when looking laterally, loss of spontaneous retinal venous pulsations or papilledema, focal neurologic deficits Aggravated by recumbency; worse on awakening or awakens patient from sleep | Neuroimaging |
* Clinical examination is always done but is mentioned in this column only when that can be the sole means of diagnosis. | ||
† Primary headaches are usually recurrent. | ||
BP = blood pressure; CSF = cerebrospinal fluid; ESR = erythrocyte sedimentation rate. | ||