Headaches- What not to miss overnight...

Overwhelmingly, most headaches are benign, but we can’t miss patients who present with a life-threatening headache!  

Review Primary Causes of Headaches: Migraine, Cluster, Tension

Secondary Headaches:
Headaches that are caused by another condition; these should be considered in patients presenting with new onset headache or headache that differs from the patient's usual headache. Observational studies have highlighted various "red flags" or warning signs for potential secondary causes of headaches which require further investigation.


Causes of Secondary Headaches:

• Trauma
• post-traumatic headache
• post-concussion 
• Vascular Disorders   
• Sub-arachnoid hemorrhage (SAH)
• Acute ischemic CVA  
• Arteritis (i.e. GCA)
• Vascular Malformation (i.e. AVM)         
• Cerebral Vein Thrombosis      
• Hypertension    
• Non-Vascular Intra-cranial Disorders
• Infection (i.e. encephalitis, meningitis)
• Benign intra-cranial HTN (i.e. Pseudotumor cerebri)
• Alteration in CSF pressure (i.e. post- LP headache)
• Associated with Substance Abuse or Withdrawal
• Multiple culprits; take a good substance use history!
• Associated with generalized infection (non-neurological)
• i.e. influenza, common cold, sinusitis, dental infection
• Associated Metabolic Disorder
• i.e. hypoxemia, hypercapnia, hypoglycemia, post-dialysis

Red Flag Features: require further work-up and investigation

• new onset of headache in a patient >50 years of age
• "Thunderclap" headache: rapid time from onset to peak intensity (seconds to 5 minutes)
• Focal Neurological Symptoms (i.e. limb weakness)
• Non-Focal Neurological symptoms (i.e. Cognitive disturbance)
• Change in frequency, characteristic, or associated symptoms
• Abnormal neurological examination
• Associated Fever and/or meningeal signs
• New onset Headache in an immune-compromised patient (i.e. HIV)
• Jaw claudication and/or associated visual disturbance 
• New onset of headache in a patient with known malignancy
• Headache that changes with posture or is worse with exertion/valsalva; worse in the morning
• New onset headache in a patient with risk factors for Cerebral Vein Thrombosis

Previous Headaches: the absence of similar headaches in the past may suggest a serious disorder. The “worst headache of my life” can be described in the setting of ICH or CNS infection

•        i.e. AIDs patient or patient with malignancy: a new or unusual headache may suggest an intra-cranial lesion or infection
• 
  
•      Concomitant infection: lungs, sinusesà nidus for infectionà meningitis or intra-cranial abscess

Altered mental status or seizure: Also consider infection (encephalitis, meningitis)

Headache with exertion — The rapid onset of headache with exertion (sexual intercourse, exercise), especially when minor trauma has occurred, raises the possibility of carotid artery dissection or intracranial hemorrhage

Age over 50 — with new onset or progressively worsening headache are at significantly greater risk of a dangerous cause of their symptoms, including an intracranial mass lesion and temporal arteritis

HIV and immunosuppression —significant risk for intracranial disease, including toxoplasmosis, stroke, brain abscess, meningitis, and malignancy of the CNS.

Visual disturbances — Occasionally patients with significant ophthalmologic disease;

•        Acute narrow angle glaucoma (ANAG), Giant Cell Arteritis (GCA)

Family history — Hx of SAH among first or second-degree relatives is at significantly greater risk of SAH

Medications:  Anti-coagulants (and recent falls!), Glucocorticoids (immune-suppressed); Analgesics (mask the pain; may exacerbate migraines via the rebound effect); Sympathomimetics: associated with intracranial bleeding.

Illicit drugs: some that increase the risk of stroke & ICH (cocaine, methamphetamine, sympathomimetics)

Toxic exposure: Carbon monoxide (CO) poisoning (i.e. winter months, family history of similar symptoms among family members who live in the same home, was the CO detector working/recently checked?)

Additional history

• Trauma (head), toxic exposures
• Co-morbidities: malignancy (risk of mets), PCKD or CNTD (increase risk of aneurysms with resultant SAH)
•  Jaw claudication: GCA 

High Risk Findings on Exam

-Vital Signs: HTN (CVA, HTN Emergency), Fever (infection)

• Focal neurological abnormalities
• Altered mental status (AMS)
• Obtundation, confusion (i.e. meningitis, encephalitis, space-occupying lesion, ICH)
• Meningismus (? Meningitis, SAH)

·       Ophthalmological Exam:

o    Papilledema (blurring of optic disks): increased ICP (structural, tumor)

o    Retinal Hemorrhage: SAH

o    Decline or loss of vision: ? Vascular compromise (GCA or carotid artery dissection, or increased IOP in ANAG)

o    Ciliary flush & sluggish pupillary light response can also occur with ANAG

·       Trauma: contusions, signs of basilar skull fracture (hemotympanum, peri-orbital ecchymosis)

NOTE: neurological abnormalities can occur with migraines (i.e. Visual field cut in both eyes within the same hemi-field bounded by scintillations—“visual aura”); however, a focal neurological deficit, should not be assumed to be related to the migraine unless similar deficits have occurred in the past

DO NOT MISS:

• Sub-arachnoid hemorrhage (SAH), Sub-dural hematoma, etc
• CVA
• Giant cell arteritis (GCA)/Temporal Arteritis 
• Hypertensive Urgency/Emergency
• Dissection
• Meningitis, Encephalitis 
• Cerebral Vein Thrombosis (CVT)
• Acute Angle Closure Glaucoma

RESOURCES:

Evaluation of Acute Headache in Adults, American Family Physician. 2001 Feb 15; 63(4):685-693

Diagnosis and Management of Headache in Adults; SIGN Guidelines (2008)