Approach to Headache

Some general thoughts:

The lifetime prevalence for headache is 99% in women & 94% in men. Therefore we can’t perform imaging on everyone. Most headaches are primary headaches Chronic headaches are usually primary headaches e.g. migraine, tension. Primary headaches are treatable in most cases. Therefore we need to recognise them. Secondary headaches may be serious. Therefore we need to recognise them. As always, if a patient needs investigations. The patient needs investigations.

The approach:

The approach to patients presenting with headache begins with a thorough history and physical examination. The neurological exam should include fundoscopy. The initial question to answer is whether the headache is a primary headache disorder i.e. a disorder on-to itself such as migraine headache, or whether it is a secondary headache disorder i.e. headache due to medical condition such as meningitis or subarachnoid hemorrhage. Looking for the headache “red flags” which are history or physical exam findings that suggest a secondary headache disorder is paramount.
Routine neuroimaging is not necessary in patients without headache red-flags, who also meet criteria for a primary headache disorder. However, in patients have a headache red-flag further investigations are paramount. In patients with uncharacterizable headaches, a low threshold for investigation is also probably prudent.

History questions:

  • General pain questions:
    • Site, character, radiation
    • Onset, duration, frequency, pattern of progression (getting worse, getting better, the same etc.)
    • Severity
    • Precipitating factors
    • Aggravating factors; specifically:
      • Light
      • Sound
    • Relieving factors, specifically:
      • What pain killers?
      • How much pain killers?
    • Associated symptoms, specifically:
      • Nausea, vomiting
      • Muscle aches ‘myalgia’, weight loss
      • Ipsilateral rhinorrhea & lacrimation
      • General neurological symptoms: Weakness, loss of sensation, visual disturbances, dizziness, loss of balance
    • Have you ever had a headache like this before?
    • Recent head trauma?
    • Pattern during the day i.e. always in the morning, same time each day, wakes one up from sleep
    • How does it affect your life?
    • Daily variation


  • Vital signs
  • Fundoscopy
  • Tests for meningeal irritation:
    • Passive neck flexion (neck stiffness, Brudzinski’s sign i.e. hip flexion)
    • Test for Kernig’s sign by flexing the hip & then extending the knee
    • Jolt accentuation: ask the patient to rotate his head horizontally, at of 2-3 rotations per second. Worsening of a baseline headache represents a positive sign of meningitis
  • Mental status
  • Test cranial nerves
  • Test limbs


Red flags for headache (suggest secondary headache):

  • Immunosuppression (AIDS, chemotherapy)
  • Headache with focal neurological deficit
  • Headache with decreased level of consciousness
  • Headache with papilledema
  • Headache with fever
  • Sudden severe headache
  • Headache after age 50 years old
  • Headache after head trauma
  • Headache during sex
  • New onset headache or change of headache character
  • Worsening headache on setting up or standing
  • Headaches with history or risk factors for a hypercoaguable state


Features of the main headaches:


  • Unilateral or less commonly bilateral, with or without aura, usually throbbing, more than an hour & less than a day. It can be occipital, may start as a neck pain or sinus pain.
  • Moderate to severe
  • Associated with nausea & vomiting, photophobia & phonophobia

Tension headache:

  • Bilateral, usually occipital, nonthrobbing, like a tight band around the head.
  • Mild to moderate
  • Not associated with nausea, vomiting or visual disturbances

Cluster headache:

  • Always unilateral, occurs in clusters of weeks to months, each headache lasts from minutes to 2 hours, nonthrobbing,
  • May awaken one from sleep, may occur at the same time every day
  • Very severe
  • Associated with ipsilateral lacrimation, nasal stuffiness & discharge

Subarachnoid hemorrhage:

  • Sudden attack of worse headache in the patients life, or headache with rapid onset to maximum pain within a few seconds a.k.a. thunderclap. Or headache during sex or orgasm.
  • Associated with warning headaches, seizures, decreased consciousness, neck stiffness, neck pain, III nerve or VI nerve palsy, Babinski’s sign

Raised intracranial pressure:

  • Usually bifrontal, dull, steady progression, worse on laying down & after coughing, sneezing or straining, worse in the morning,
  • Mild to moderate
  • Associated with vomiting, drop attacks


Investigations to consider:

  • Noncontrast CT head if red flags are present
  • MRI, MRV: cerebral venous sinus thrombosis CVST, deep vein thrombosis DVST
  • ESR & CRP if >50 y.o.: giant cell arteritis
  • Lumbar puncture with opening pressure & CSF analysis: acute meningitis, chronic meningitis, venous sinus thrombosis,
  • MRA, Catheter angiography: Reversible cerebral vasoconstriction syndrome RCVS
  • Catheter angiography: Reversible cerebral vasoconstriction syndrome RCVS, Primary angiitis of the CNS PACNS
  • If episodic & recurrent, consider headache diary


Causes of headache by etiology:

Primary headache disorders:

Secondary headache disorders:


Causes of headache by acuity:


Subacute: weeks to months

Chronic: months to years

Classification of headaches, modified from IHC:

Primary headaches:

Trigeminal neuralgias & central facial pain

Secondary headaches:

Secondary causes of facial pain or trigeminal distribution pain:

  • Ophthalmoplegic ‘migraine’
  • Tolosa-Hunt syndrome
  • Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesions
  • Optic neuritis
  • Ocular diabetic neuropathy
  • Head or facial pain attributed to herpes zoster
  • Head or facial pain attributed to acute herpes zoster- Post-herpetic neuralgia
  • Central causes of facial pain
  • Anaesthesia dolorosa
  • Central post-stroke pain
  • Facial pain attributed to multiple sclerosis

Indomethacin-responsive headache syndromes: