There are MANY primary and secondary causes of headache:
There are MANY causes of secondary intracranial headache:
Consider the SNNOOP10 mnemonic for headache red flags!
- S ystemic symptoms, including fever
- N eoplasm history
- N eurologic deficit
- O nset is sudden, abrupt
- O older age (onset >50 years)
- P ositional headache
- P attern change or recent onset of new headache
- P recipitated by sneezing, coughing
- P apilledema
- P rogressive headache
- P regnancy or puerperium
- P ainful eye, autonomic features
- P ost-traumatic onset
- P athology of immune system
- P ainkiller overuse
- Age, gender profession
- Duration of headache
- Location/ irradiation
- Qualitative characteristics
- What time of day does pain start and how long does it last
- What is the frequency of the headaches
- Triggering events, relieving and aggravating factors
- Related symptoms
- Medications and frequency of administration
HEADACHE with Systemic symptoms
- Many possibilities: fever, nuchal rigidity, altered mental status, photophobia, confusion, petechial rash, weight loss, etc.
Evaluation: Consider head CT, LP, blood cultures
DDx: bacterial meningitis, encephalitis, fungal meningitis, aseptic meningitis, autoimmune neurosarcoidosis, Behcet syndrome
- Thunderclap headache that reaches maximal intensity within seconds to a minute
- Explosive and unexpected
- May have associated neurological deficits (e.g., hemiparesis, oculomotor deficits)
- Consider history of anticoagulant use or trauma, nausea, vomiting, or meningismus
Evaluation: Consider head CT, LP (xanthochromia?)
DDx: Subarachnoid hemorrhage, AVM rupture, aneurysm rupture, reversible cerebral vasoconstriction syndrome
- Headache with upright or sitting position
- Resolves with recumbency
- May be associated with tinnitus, vertigo, dizziness, nuchal rigidity/pain, unsteady gait, diaphoresis, anorexia, etc.
Evaluation: Consider MRI brain/spine, LP
DDx: Spontaneous hypotension headache, post-LP CSF leak, CSF shunt malfunction, cervicogenic, Chiari I malformation
HEADACHE Aggravated by coughing/sneezing
- Aggravated by valsalva, cough or bending over
- May be associated with nausea, vomiting, fever, worsening/progressive headache, focal neurological deficits, papilledema, new-onset seizures, fatigue, or cognitive dysfunction
Evaluation: Consider MRI brain (vs head CT), LP
DDx: Primary intracranial tumors, metastasis, abscesses, chronic subdural hematoma, ICP
New-onset headache in older patient
- Patients over 50 years or age
- May be associated with fever, fatigue, weight loss, jaw claudication, diplopia, or transient monocular vision loss
Evaluation: Consider temporal artery biopsy, head CT, color doppler ultrasound
DDx: Giant cell arteritis, trigeminal neuralgia, acute herpes zoster, post herpetic neuralgia
headache with Blurry vision
- Blurry vision has many forms: diplopia, vision loss, etc.
- May be associated with nausea, loss of coordination and balance, headaches upon waking early in the morning, or unilateral blurry vision/seeing halos
Evaluation: Consider fundoscopy, head CT, LP (elevated opening pressure?)
DDx: Pseudotumor cerebri, hydrocephalus, tumor, acute hypertension, glaucoma, cavernous sinus thrombosis
headache with Painful eye
- May have associated autonomic features (e.g., lacrimation, miosis, ptosis, rhinorrhea), conjunctival injection, vision loss, seeing halos
Evaluation: Consider fundoscopy, MRI brain
DDx: Optic neuritis, glaucoma, cluster headache, migraine, trigeminal autonomic cephalgia, Cavernous sinus thrombosis, draining AVM
- Any recent trauma or injury?
- May have associated confusion, loss of consciousness, memory loss, acute worsening
Evaluation: head CT vs MRI brain
DDx: Concussion syndrome, TBI
headache with Acute neck pain
- May have associated Horner’s syndrome or focal deficits
Evaluation: Consider CTA, MRA, Doppler
DDx: Cervical artery dissection (carotid dissection, vertebral artery dissection)
headache in the immunosuppressed patient
- May have associated low CD-4 count, photophobia, pain with eye movement, altered mental status, confusion, or focal deficits
Evaluation: head CT, MRI brain, LP
DDx: Cryptococcal meningitis, toxoplasmosis, JC virus, acute HIV encephalitis
headache in Pregnancy / postpartum
- Concerning features would include new onset, throbbing, diffuse (holocephalic), constant, blurry vision, photophobia, scotoma, diplopia, hemianopsia, focal deficits
Evaluation: BP, Cr, fundoscopy, MRI brain or CT head
DDx: Preeclampsia with severe features (includes HA), cerebral venous thrombosis, stroke
24yo woman with history of IV drug use is admitted with shortness of breath and lower extremity edema. Overnight, she develops new onset headache and associated confusion.
- What are the red flags?
- What’s your DDx?
- What would you do next?
45yo woman presents with sudden onset severe headache, 2 episodes of vomiting, and photophobia without neurological deficit. 10 days ago, she was evaluated for these exact symptoms and underwent non-contrast head CT (unremarkable) followed by an LP (also unremarkable). She then saw a neurologist in follow-up who subsequently diagnosed her with reversible cranial vasoconstriction syndrome (RCVS).
- What is your next step?
24yo woman with homozygous factor V Leiden presents with sudden onset headaches after recently starting OCP.
- What is likely cause of her headache?
- What are the red flags?
- In what other patients would you be concerned about this presentation?
Blog post based on Med-Peds Forum talk by Cecilia Paasche, PGY1, and Tabitha N’dungu, PGY1