Current Clinical Issue

Activity for 2018

Activity No: MP5 (18) Part 1 & 2 (2022)

Topic

Headache

Article

Evaluation of headache in adults

Part 1 Approved for TWO (2) Clinical Continuing Educational Units (CEU’s)

Part 2 Approved for THREE (3) Clinical Continuing Educational Units (CEU’s)

MP5(18)

Evaluation of headache in adults Authors Zahid H Bajwa, MD R Joshua Wootton, MDiv, PhD Section Editor Jerry W Swanson, MD, MHPE Deputy Editors John F Dashe, MD, PhD Susanna I Lee, MD, PhD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2017. | This topic last updated: Dec 20, 2016.

INTRODUCTION — Headache is among the most common medical complaints. An overview of the approach to the patient with headache is presented here. The approach to adults presenting with headache in the emergency department is reviewed elsewhere. (See "Evaluation of the adult with headache in the emergency department".)

The clinical features and management of specific primary headache syndromes are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis" and "Cluster headache: Epidemiology, clinical features, and diagnosis".)

EPIDEMIOLOGY AND CLASSIFICATION — As many as 90 percent of all benign headaches fall under a few categories, including migraine, tension-type, cluster, and chronic daily headache. While episodic tension-type headache is the most frequent headache type in population-based studies, migraine is the most common diagnosis in patients presenting to primary care physicians with headache. The one-year prevalence of episodic tension-type headache (TTH) is approximately 65 percent (see "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis", section on 'Epidemiology'), but most people with tension-type headache do not present to physicians for care. As an example, a study of two primary care units in Brazil found that migraine was the most prevalent primary headache disorder, accounting for 45 percent of patients reporting headache as a single symptom [1].

Cluster headache typically leads to significant disability and most of these patients will come to medical attention. However, cluster headache remains an uncommon diagnosis in primary care settings because of overall low prevalence in the general population (<1 percent). (See "Cluster headache: Epidemiology, clinical features, and diagnosis", section on 'Epidemiology'.)

Clinicians can easily become familiar with the most common primary headache disorders and how to distinguish them (table 1).

Migraine — Migraine is a disorder of recurrent attacks. The headache of migraine is often but not always unilateral and tends to have a throbbing or pulsatile quality. Accompanying features may include nausea, vomiting, photophobia, or phonophobia during attacks. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)

Migraine trigger factors (table 2) may include stress, menstruation, visual stimuli, weather changes, nitrates, fasting, wine, sleep disturbances, and aspartame, among others. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on 'Precipitating and exacerbating factors'.)

Tension-type headache — The typical presentation of a TTH attack is that of a mild to moderate intensity, bilateral, nonthrobbing headache without other associated features. Pure TTH is a rather featureless headache. (See "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis".)

Cluster headache — Cluster headache belongs to a group of idiopathic headache entities, the trigeminal autonomic cephalalgias (table 3), all of which involve unilateral, often severe headache attacks and typical accompanying autonomic symptoms. Cluster headache is characterized by attacks of severe unilateral orbital, supraorbital, or temporal pain accompanied by autonomic phenomena. Unilateral autonomic symptoms are ipsilateral to the pain and may include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. Attacks usually last 15 to 180 minutes. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".)

Cluster headache may sometimes be confused with a life-threatening headache, since the pain from a cluster headache can reach full intensity within minutes. However, cluster headache is transient, usually lasting less than one to two hours.

Secondary headache — Physicians who evaluate patients with headache should be alert to signs that suggest a serious underlying disorder. (See 'Danger signs' below and 'Patient settings' below.)

In the Brazilian primary care study, 39 percent of patients presenting with headache had a headache that was due to a systemic disorder (most commonly fever, acute hypertension, and sinusitis), and 5 percent had a headache that was due to a neurologic disorder (most commonly post-traumatic headache, headaches secondary to cervical spine disease, and expansive intracranial processes) [1].

Misconceptions — A number of misconceptions may hinder headache evaluation and diagnosis.

●Although sinus headache is commonly diagnosed by physicians and self-diagnosed by patients, acute or chronic sinusitis appears to be an uncommon cause of recurrent headaches, and many patients presenting with sinus headache turn out to have migraine [2-4]. (See 'Sinus symptoms' below.)

●Patients frequently attribute headaches to eye strain. However, an observational study suggested that headaches are only rarely due to refractive error alone [5]. Nevertheless, correcting vision may improve headache symptoms in some of these patients. ●There is a common belief, particularly among patients, that hypertension can cause headaches. While this is true in the case of hypertensive emergencies, it is probably not true for typical migraine or tension headaches. As an example, a report from the Physicians' Health Study of 22,701 American male physicians ages 40 to 84 years analyzed various risk factors for cerebrovascular disease and found no difference in the percentage of men with a history of hypertension in the migraine and nonmigraine groups [6]. Furthermore, a prospective study of 22,685 adults in Norway found that high systolic and diastolic pressures were actually associated with a reduced risk of nonmigrainous headache [7].

EVALUATION — The appropriate evaluation of headache complaints includes the following:

●Rule out serious underlying pathology and look for other secondary causes of headache (algorithm 1). ●Determine the type of primary headache using the patient history as the primary diagnostic tool (table 1). There may be overlap in symptoms, particularly between migraine and tension-type headache and between migraine and some secondary causes of headache such as sinus disease.

A systematic case history is the single most important factor in establishing a headache diagnosis and determining the future work-up and treatment plan. An imaging study is not necessary in the vast majority of patients presenting with headache. Nevertheless, brain imaging is warranted in the patients with danger signs suggesting a secondary cause of headache. (See 'Indications for imaging studies' below.)

History and examination — A thorough history can focus the physical examination and determine the need for further investigations and neuroimaging studies. A systematic history should include the following:

●Age at onset ●Presence or absence of aura and prodrome ●Frequency, intensity, and duration of attack ●Number of headache days per month ●Time and mode of onset ●Quality, site, and radiation of pain ●Associated symptoms and abnormalities ●Family history of migraine ●Precipitating and relieving factors ●Effect of activity on pain ●Relationship with food/alcohol ●Response to any previous treatment ●Any recent change in vision ●Association with recent trauma

●Any recent changes in sleep, exercise, weight, or diet ●State of general health ●Change in work or lifestyle (disability) ●Change in method of birth control (women) ●Possible association with environmental factors ●Effects of menstrual cycle and exogenous hormones (women)

The examination of an adult with headache complaints should cover the following areas:

●Obtain blood pressure and pulse ●Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation ●Palpate the head, neck, and shoulder regions ●Check temporal and neck arteries ●Examine the spine and neck muscles

The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests. Gait examination should include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and Romberg test.

The majority of patients with headache complaints have a completely normal physical and neurologic examination. However, some types of primary headache may be associated with specific abnormalities:

●With tension-type headache, there may be pericranial muscle tenderness. ●With migraine, there may be manifestations related to sensitization of primary nociceptors and central trigeminovascular neurons, such as hyperalgesia and allodynia. ●With hemicrania continua or one of the other trigeminal autonomic cephalalgias (cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks), there may be evidence of autonomic activation.

Other abnormalities on examination should raise suspicion for a secondary headache disorder. Likewise, danger signs (ie, red flags) should prompt further evaluation, as discussed in the sections below.

Danger signs — Paying attention to danger signs is important since headaches may be the presenting symptom of a space-occupying mass or vascular lesion, infection, metabolic disturbance, or a systemic problem. The following features in the history can serve as warning signs of possible serious underlying disease [8-10]. (See "Evaluation of the adult with headache in the emergency department".)

The mnemonic SNOOP is a reminder of the danger signs ("red flags") for the presence of serious underlying disorders that can cause acute or subacute headache [11,12]:

●Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised state including HIV)

●Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures) ●Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap") ●Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity) ●Previous headache history with headache progression or change in attack frequency, severity, or clinical features

Any of these findings should prompt further investigation, including brain imaging with MRI or CT. (See 'Indications for imaging studies' below.)

Other features suggesting a secondary headache source — Other features that suggest a specific source of headache pain include the following:

●Impaired vision or seeing halos around light suggests the presence of glaucoma. Suspicion for subacute angle closure glaucoma should be raised by relatively short duration (often less than one hour) unilateral headaches that do not meet criteria for migraine arising after age 50 [13]. ●Visual field defects suggest the presence of a lesion of the optic pathway (eg, due to a pituitary mass). ●Sudden, severe, unilateral vision loss suggests the presence of optic neuritis. (See "Optic neuritis: Pathophysiology, clinical features, and diagnosis".) ●Blurring of vision on forward bending of the head, headaches upon waking early in the morning that improve with sitting up, and double vision or loss of coordination and balance should raise the suspicion of raised intracranial pressure; this should also be considered in patients with chronic, daily, progressively worsening headaches associated with chronic nausea. ●In patients who present with headache that is relieved with recumbency and exacerbated with upright posture, the diagnosis of headache attributed to spontaneous intracranial hypotension should be considered. An additional major feature of this headache syndrome is diffuse meningeal enhancement on brain MRI. The accepted etiology is cerebrospinal fluid (CSF) leakage, which may occur in the context of rupture of an arachnoid membrane. (See "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis".) ●The presence of nausea, vomiting, worsening of headache with changes in body position (particularly bending over), an abnormal neurologic examination, and/or a significant change in prior headache pattern suggests the headache was caused by a tumor. (See "Overview of the clinical features and diagnosis of brain tumors in adults".) ●Intermittent headaches with high blood pressure are suggestive of pheochromocytoma. (See "Clinical presentation and diagnosis of pheochromocytoma".) ●Morning headache is nonspecific and can occur as part of a primary headache syndrome or may be secondary to a number of disorders including sleep apnea, chronic obstructive pulmonary disease, and the obesity hypoventilation syndrome. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Chronic obstructive pulmonary

disease: Definition, clinical manifestations, diagnosis, and staging" and "Clinical manifestations and diagnosis of obesity hypoventilation syndrome".)

Diagnostic instruments — As mentioned above, the most common headache syndromes frequently present with characteristic symptoms (table 1). However, there may be considerable symptom overlap; one population-based survey found that less than one-half of patients who complained of headaches that met criteria for migraine were properly diagnosed [14]. Migraine symptoms may also overlap with other causes of headache. As an example, a significant number of patients with migraine may have nasal symptoms that suggest sinus disease [15]; in addition, a study of primary care patients with recurrent sinus headache found that 90 percent experienced attacks that met the International Headache Society (IHS) criteria for migraine [16]. (See 'Sinus symptoms' below.)

Given these pitfalls, a number of diagnostic instruments have been proposed, mainly to assist with the diagnosis of migraine, the most common primary headache syndrome in patients presenting to primary care physicians. One such instrument (ID Migraine) preselects eligible subjects as those who had two or more headaches in the previous three months and indicated either that they might want to speak with a healthcare professional about their headaches or that they experienced a headache that limited their ability to work, study, or enjoy life [17]. The screen employs three questions:

During the last three months, did you have the following with your headaches?

●You felt nauseated or sick to your stomach ●Light bothered you (a lot more than when you don't have headaches) ●Your headaches limited your ability to work, study, or do what you needed to do for at least one day

The ID migraine screen is positive if the patient answers yes to two of the three items. In a systematic review of 13 studies that involved over 5800 patients, the pooled sensitivity and specificity of ID migraine was 0.84 and 0.76, respectively [18]. A positive ID migraine increased the pretest probability of migraine from 59 to 84 percent, whereas a negative ID Migraine score reduced the probability of migraine from 59 to 23 percent.

Another simple and validated instrument, the brief headache screen, consists of three to six questions [19]. One version includes the following four questions:

●How often do you get severe headaches (ie, without treatment it is difficult to function)? ●How often do you get other (milder) headaches? ●How often do you take headache relievers or pain pills? ●Has there been any recent change in your headaches?

In one study, the presence of episodic disabling headache correctly identified migraine in 136 of 146 patients (93 percent) with episodic migraine, and 154 of 197 patients (78 percent) with chronic headache with migraine, with a specificity of 63 percent [19]. Only 6 of

343 patients (2 percent) with migraine were not identified by disabling headache. Thus, virtually any patient with severe episodic headaches can be considered to have migraine.

Questions 2 and 3 can be helpful for identifying patients with medication overuse (eg, patients who use symptomatic medications more than three days per week and/or who have daily headaches). Question 4 is particularly helpful for identifying patients who may have an important secondary cause of headache; a patient with a stable pattern of headache for six months is unlikely to have a serious underlying cause.

Indications for imaging studies — Patients with any of the danger signs noted above need urgent brain imaging (see 'Danger signs' above). Our approach is to perform neuroimaging in the following situations [20]:

●Focal neurologic signs or symptoms ●Onset of headache with exertion, cough, or sexual activity ●Orbital bruit ●Onset of headache after age 40 years ●Recent significant change in the pattern, frequency, or severity of headaches ●Progressive worsening of headache despite appropriate therapy

MRI is the preferred brain imaging modality for most patients because it is more sensitive than CT scan for detecting edema, vascular lesions, and other types of intracranial pathology, particularly in the posterior fossa. However, CT is more widely available and is therefore more useful in urgent or emergency care situations when there is concern for subarachnoid hemorrhage as the cause of thunderclap headache.

It may also be reasonable to image a patient presenting with nonmigrainous featureless headache, ie, bilateral nonthrobbing headache without nausea and without sensitivity to light, sound, or smell [21]. Such an approach would have an estimated yield of 2 percent for detecting a treatable cause.

In the remaining patients, there are no randomized, controlled trials that help delineate when imaging is necessary, and no such trials are likely to be forthcoming as blinding and randomization would present ethical problems. As a result, the decision to scan or not to scan in headache is likely to remain one of clinical judgment [21].

The vast majority of patients without danger signs do not have a secondary cause of headache [22,23]. As an example, in a study of 373 patients with chronic headache at a tertiary referral center, all had one or more of the following characteristics that prompted referral for head CT scanning: increased severity of symptoms or resistance to appropriate drug therapy, change in characteristics or pattern of headache, or family history of an intracranial structural lesion [24]. Only four scans (1 percent) showed significant lesions (two osteomas, one low grade glioma, and one aneurysm); only the aneurysm was treated.

Neuroimaging is usually not warranted for patients with migraine and a normal neurologic examination, although a lower threshold for imaging is reasonable for patients with atypical migraine features or in patients who do not fulfill the strict definition of migraine [25].

However, brain imaging for no other reason than reassurance is sometimes performed in clinical practice. In the end, patients are seeking a reason for the problem. It is important that the clinician provide the patient with a clear explanation of both the diagnosis and the reason for the brain scan, especially if the decision is made to obtain imaging in someone suspected of having primary headache [21].

Indications for lumbar puncture — Lumbar puncture (LP) for cerebrospinal fluid analysis is urgently indicated in patients with headache when there is clinical suspicion of subarachnoid hemorrhage in the setting of a negative or normal head CT scan. In addition, LP is indicated when there is clinical suspicion of an infectious or inflammatory etiology of headache. These issues are discussed elsewhere. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage", section on 'Diagnosis of subarachnoid hemorrhage' and "Lumbar puncture: Technique, indications, contraindications, and complications in adults".)

PATIENT SETTINGS — Differences in patient demographics, comorbidities, and headache features can guide the evaluation to help ensure appropriate diagnosis and management. Regardless of the setting, adults presenting with a chief complaint of new severe headache require urgent evaluation (algorithm 1).

Emergency — The evaluation of the adult presenting to the emergency department with headache is reviewed in detail elsewhere (see "Evaluation of the adult with headache in the emergency department"). The main goal of the evaluation is to differentiate the relatively small number of patients with serious or life-threatening headaches from the majority with benign primary headaches.

Sudden onset — Severe headache of sudden onset (ie, that reaches maximal intensity within a few seconds or less than one minute after the onset of pain) is known as thunderclap headache because its explosive and unexpected nature is likened to a "clap of thunder." Thunderclap headache requires urgent evaluation as such headaches may be harbingers of subarachnoid hemorrhage and other potentially ominous etiologies (table 4). These include cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, ischemic stroke, acute hypertensive crisis with reversible posterior leukoencephalopathy syndrome, "orgasmic" headache associated with sexual activity, third ventricular colloid cysts, bacterial and viral meningitis, complicated sinusitis, and reversible cerebral vasoconstriction syndromes. (See "Approach to the patient with thunderclap headache".)

For all patients with thunderclap headache, we recommend head CT and, if head CT is normal, lumbar puncture with measurement of opening pressure and cerebrospinal fluid analysis to exclude subarachnoid hemorrhage. For patients with thunderclap headache who have nondiagnostic head CT and lumbar puncture, imaging of the cerebral circulation is necessary. We suggest obtaining brain MRI and noninvasive neurovascular imaging such as MR or CT angiography/venography. (See "Approach to the patient with thunderclap headache", section on 'Diagnostic evaluation'.)

New or recent onset headache — The absence of similar headaches in the past is another finding that suggests a possible serious disorder.

●New headache in patients older than 40 years may suggest underlying pathology ●New headache type in a patient with cancer suggests metastasis ●New headache type in a patient with Lyme disease suggests meningoencephalitis ●New headache type in a patient with HIV suggests an opportunistic infection or tumor

In contrast, patients with migraine usually have had similar types of headaches in the past.

Brain tumor is a rare cause of headache but should be considered in patients presenting with focal neurologic signs. It should also be considered when new-onset headaches occur in adults older than 50 years. A prior history of headache does not rule out the possibility of brain tumor, and a change in headache pattern is a diagnostic "red flag." The features of brain tumor headache are generally nonspecific and vary widely with tumor location, size, and rate of growth. The headache is usually bilateral, but can be on the side of the tumor. Brain tumor headache often resembles tension-type headache, but may resemble migraine or a variety of other headache types. (See "Brain tumor headache".)

Chronic headache — Chronic daily headache is not a specific headache type, but a syndrome that encompasses a number of primary and secondary headaches. The term "chronic" refers either to the frequency of headaches or to the duration of the disease, depending upon the specific headache type. (See "Overview of chronic daily headache".)

With headache subtypes of long duration (ie, four hours or more), "chronic" indicates a headache frequency of 15 or more days a month for longer than three months in the absence of organic pathology. These headache subtypes are:

●Chronic migraine headache (see "Chronic migraine") ●Chronic tension-type headache (see "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis") ●Medication overuse headache, which is typically preceded by an episodic headache disorder (usually migraine or tension-type headache) that has been treated with frequent and excessive amounts of acute symptomatic medications (see "Medication overuse headache: Etiology, clinical features, and diagnosis") ●Hemicrania continua, a strictly unilateral, continuous headache with superimposed exacerbations of moderate to severe intensity accompanied by autonomic features and sometimes by migrainous symptoms (see "Hemicrania continua") ●New daily persistent headache, characterized by headache that begins rather abruptly and is daily and unremitting from onset or within three days of onset at most, typically in individuals without a prior headache history (see "New daily persistent headache")

With headache subtypes of shorter duration (ie, less than four hours), "chronic" refers to a prolonged duration of the condition itself without remission. The headache subtypes in this category are the following:

●Chronic cluster headache (see "Cluster headache: Epidemiology, clinical features, and diagnosis") ●Chronic paroxysmal hemicrania, characterized by unilateral, brief, severe attacks of pain associated with cranial autonomic features that recur several times per day with individual headache attacks that usually last 2 to 30 minutes (see "Paroxysmal hemicrania: Clinical features and diagnosis") ●Short-lasting unilateral neuralgiform headache attacks, characterized by sudden brief attacks of severe unilateral head pain in orbital, peri-orbital, or temporal regions, accompanied by ipsilateral cranial autonomic symptoms (see "Short-lasting unilateral neuralgiform headache attacks: Clinical features and diagnosis") ●Hypnic headache, also known as "alarm clock headache," which occurs almost exclusively after the age of 50 years and is characterized by episodes of dull head pain, often bilateral, that awaken the sufferer from sleep (see "Hypnic headache") ●Primary stabbing headache, characterized by sudden brief attacks of sharp, jabbing head pain in orbital, peri-orbital, or temporal regions (see "Primary stabbing headache")

Older patients — Older patients are at increased risk for secondary types of headache (eg, giant cell arteritis, trigeminal neuralgia, subdural hematoma, acute herpes zoster and postherpetic neuralgia, and brain tumors) and some types of primary headache (hypnic headache, cough headache, and migraine accompaniments) [26].

●Giant cell (temporal) arteritis is a chronic vasculitis of large and medium sized vessels. The greatest risk factor for developing giant cell arteritis is aging. The disease seldom occurs before age 50 years, and its incidence rises steadily thereafter. A new type of headache occurs in two-thirds of affected individuals. The head pain tends to be located over the temporal areas but can be frontal or occipital in location. The headaches may be mild or severe. Other common symptoms include fever, fatigue, weight loss, jaw claudication, visual symptoms, particularly transient monocular visual loss and diplopia, and symptoms of polymyalgia rheumatica. (See "Clinical manifestations of giant cell (temporal) arteritis".) ●Trigeminal neuralgia is defined clinically by sudden, usually unilateral, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve. The incidence increases gradually with age; most idiopathic cases begin after age 50 years. (See "Trigeminal neuralgia".) ●Chronic subdural hematoma may present with the insidious onset of headaches, light-headedness, cognitive impairment, apathy, somnolence, and occasionally seizures. (See "Subdural hematoma in adults: Etiology, clinical features, and diagnosis".) ●Acute herpes zoster and postherpetic neuralgia often involve cervical and trigeminal nerves. Pain is the most common symptom of zoster and approximately 75 percent of patients have prodromal pain in the dermatome where the rash subsequently appears. The major risk factors for postherpetic neuralgia are older age, greater acute pain, and greater rash severity. (See "Clinical manifestations of varicella-zoster virus infection: Herpes zoster" and "Postherpetic neuralgia".) ●Brain tumor should be considered as a possible cause of new-onset headaches in adults over age 50 years, as discussed above. (See 'New or recent onset headache' above and "Brain tumor headache".)

●Hypnic headache, also known as "alarm clock headache," occurs almost exclusively after the age of 50 years and is characterized by episodes of dull head pain, often bilateral, that awaken the sufferer from sleep. (See "Hypnic headache".) ●Primary cough headache most often affects people older than age 40 years and is provoked by coughing or straining in the absence of any intracranial disorder. (See "Primary cough headache".) ●Late-life migraine accompaniments are symptoms related to the onset after the age of 40 years of migraine aura without headache [27]. The most common symptoms are visual auras, followed by sensory auras (paresthesia), speech disturbances, and motor auras (weakness or paralysis). The most common presentation is gradual evolution of aura symptoms with spread of transient neurologic deficits over several minutes and serial progression from one symptom to another.

Pregnancy — New headache or change in headache during pregnancy may be due to migraine or tension-type headaches, but many other conditions can present with headache at this time, particularly pre-eclampsia, post-dural puncture headache, and cerebral venous thrombosis. Among pregnant women with the onset of new or atypical headache, approximately one-third have migraine, one-third have pre-eclampsia/eclampsia-related headache, and the remaining one-third have a variety of other causes of headache.

Pre-eclampsia must be ruled in or out in every pregnant woman over 20 weeks of gestation with headache. (See "Headache in pregnant and postpartum women".)

Fever — Fever associated with headache may be caused by intracranial, systemic, or local infection, as well as other etiologies (table 5).

Immunocompromised — New headache type in a patient with HIV or other immunocompromised state suggests an opportunistic infection or neoplasm as the cause.

Traumatic brain injury — Headache is variably estimated as occurring in 25 to 78 percent of persons following mild traumatic brain injury. Paradoxically, headache prevalence, duration, and severity is greater in those with mild head injury compared with those with more severe trauma. Most often, headache following head trauma can be classified similarly to nontraumatic headaches; migraine and tension-type headache predominate. (See "Postconcussion syndrome", section on 'Headaches'.)

Sinus symptoms — Although sinus headache is commonly diagnosed by physicians and self-diagnosed by patients, acute or chronic sinusitis appears to be an uncommon cause of recurrent headaches [2-4].

Autonomic features characteristically occur in trigeminal autonomic cephalgias such as cluster headaches and are also common with migraine headache. These symptoms may include nasal congestion, rhinorrhea, tearing, color and temperature change, and changes in pupil size. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)

The prominence of sinus symptoms often leads to the misdiagnosis of "sinus headache" in patients who meet diagnostic criteria for migraine or, less often, tension-type headache. This point is illustrated by an observational study that enrolled 2991 patients with a history of physician- or self-diagnosed sinus headache and no previous history of migraine; 88 percent of these patients fulfilled criteria for migraine or migrainous headache, and 8 percent fulfilled criteria for tension-type headache [28]. In the patients with migraine or migrainous headache, sinus pain, pressure, and congestion commonly occurred in association with typical migraine features such as pulsing head pain and sensitivity to activity, light, and sound (figure 1).

Pain related purely to sinus conditions may have some features that aid in distinguishing it from migraine [29,30]. Sinus-related pain or headache is typically described as a pressure-like or dull sensation that is usually bilateral and periorbital. However, it can be unilateral with deviated septum, middle or inferior turbinate hypertrophy, or unilateral sinus disease. In addition, sinus-related pain is typically associated with nasal obstruction or congestion, lasts for days at a time, and is usually not associated with nausea, vomiting, photophobia, or sonophobia. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)

The severity, extent, and location of sinus-related pain do not correlate with the extent or location of mucosal disease as revealed by imaging [30].

In general, the following principles apply to the relationship of rhinosinusitis and headache [29,31,32]:

●A stable pattern of recurrent headaches that interfere with daily function is most likely migraine. ●Recurrent self-limited headaches associated with rhinogenic symptoms are most likely migraine. ●Prominent rhinogenic symptoms with headache as one of several symptoms should be evaluated carefully for otolaryngologic conditions. ●Headache associated with fever and purulent nasal discharge is likely rhinogenic in origin.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Headaches in adults (The Basics)") ●Beyond the Basics topics (see "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)" and "Patient education: Headache treatment in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●While episodic tension-type headache is the most frequent headache type in population-based studies, migraine is the most common diagnosis in patients presenting to primary care physicians with headache. Clinicians can easily become familiar with the most common primary headache disorders and how to distinguish them (table 1). (See 'Epidemiology and classification' above.) ●Using the patient history as the primary diagnostic tool, the initial headache evaluation (algorithm 1) should determine whether there is a potentially dangerous secondary cause of headache or whether the headache is due to one of the common types of primary headache. (See 'Evaluation' above.) ●The mnemonic SNOOP is a reminder of the danger signs ("red flags") for the presence of serious underlying disorders that can cause acute or subacute headache:

•Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised state including HIV) •Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures) •Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap") •Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity) •Previous headache history with headache progression or change in attack frequency, severity, or clinical features

Any of these findings should prompt further investigation (algorithm 1), including brain imaging with MRI or CT. (See 'Danger signs' above and 'Indications for imaging studies' above.) ●Differences in patient demographics, comorbidities, and headache features can guide the evaluation to help ensure appropriate diagnosis and management. (See 'Patient settings' above.)

•Thunderclap headache may be the harbinger of subarachnoid hemorrhage and other potentially ominous etiologies (table 4) (see 'Sudden onset' above) •The absence of similar headaches in the past is another finding that suggests a possible serious disorder (see 'New or recent onset headache' above) •Chronic daily headache is a syndrome that encompasses a number of primary and secondary headaches (see 'Chronic headache' above) •Older patients are at increased risk for secondary types of headache (eg, giant cell arteritis, trigeminal neuralgia, subdural hematoma, acute herpes zoster and postherpetic neuralgia, and brain tumors) and some types of primary headache (hypnic headache, cough headache, and migraine accompaniments) (see 'Older patients' above)

•Pre-eclampsia must be ruled in or out in every pregnant woman over 20 weeks of gestation with headache (see 'Pregnancy' above) •Fever associated with headache may be caused by intracranial, systemic, or local infection, as well as other etiologies (table 5) (see 'Fever' above) •Headache is a frequent sequelae of mild traumatic brain injury (see 'Traumatic brain injury' above)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1 Bigal ME, Bordini CA, Speciali JG. Etiology and distribution of headaches in two Brazilian primary care units. Headache 2000; 40:241. 2 Cady RK, Schreiber CP. Sinus headache or migraine? Considerations in making a differential diagnosis. Neurology 2002; 58:S10. 3 Mehle ME. What do we know about rhinogenic headache? The otolaryngologist’s challenge. Otolaryngol Clin North Am 2014; 47:255. 4 Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache 2007; 47:213. 5 Gil-Gouveia R, Martins IP. Headaches associated with refractive errors: myth or reality? Headache 2002; 42:256. 6 Buring JE, Hebert P, Romero J, et al. Migraine and subsequent risk of stroke in the Physicians' Health Study. Arch Neurol 1995; 52:129.

7 Hagen K, Stovner LJ, Vatten L, et al. Blood pressure and risk of headache: a prospective study of 22 685 adults in Norway. J Neurol Neurosurg Psychiatry 2002; 72:463.

8 Edmeads J. Emergency management of headache. Headache 1988; 28:675. 9 Lipton RB, Bigal ME, Steiner TJ, et al. Classification of primary headaches. Neurology 2004; 63:427.

10 Lynch KM, Brett F. Headaches that kill: a retrospective study of incidence, etiology and clinical features in cases of sudden death. Cephalalgia 2012; 32:972.

11 Dodick D. Headache as a symptom of ominous disease. What are the warning signals? Postgrad Med 1997; 101:46. 12 Venkatesan A. Case 13: a man with progressive headache and confusion. MedGenMed 2006; 8:19.

13 Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR. Intermittent headaches as the presenting sign of subacute angle-closure glaucoma. Neurology 2005; 65:757.

14 Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001; 41:638. 15 Barbanti P, Fabbrini G, Pesare M, et al. Unilateral cranial autonomic symptoms in migraine. Cephalalgia 2002; 22:256. 16 Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin North Am 2004; 37:267. 17 Rapoport AM, Bigal ME. ID-migraine. Neurol Sci 2004; 25 Suppl 3:S258.

18 Cousins G, Hijazze S, Van de Laar FA, Fahey T. Diagnostic accuracy of the ID Migraine: a systematic review and meta-analysis. Headache 2011; 51:1140.

19 Maizels M, Burchette R. Rapid and sensitive paradigm for screening patients with headache in primary care settings. Headache 2003; 43:441. 20 Kumar KL, Cooney TG. Headaches. Med Clin North Am 1995; 79:261. 21 Goadsby PJ. To scan or not to scan in headache. BMJ 2004; 329:469. 22 Tsushima Y, Endo K. MR imaging in the evaluation of chronic or recurrent headache. Radiology 2005; 235:575. 23 You JJ, Gladstone J, Symons S, et al. Patterns of care and outcomes after computed tomography scans for headache. Am J Med 2011; 124:58. 24 Dumas MD, Pexman JH, Kreeft JH. Computed tomography evaluation of patients with chronic headache. CMAJ 1994; 151:1447. 25 Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000; 54:1553.

26 Hale N, Paauw DS. Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management. Med Clin North Am 2014; 98:505.

27 Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia 2015; 35:894.

28 Schreiber CP, Hutchinson S, Webster CJ, et al. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Arch Intern Med 2004; 164:1769.

29 Cady RK, Dodick DW, Levine HL, et al. Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment. Mayo Clin Proc 2005; 80:908.

30 Tarabichi M. Characteristics of sinus-related pain. Otolaryngol Head Neck Surg 2000; 122:842.

31 Levine HL, Setzen M, Cady RK, et al. An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg 2006; 134:516.

32 Marmura MJ, Silberstein SD. Headaches caused by nasal and paranasal sinus disease. Neurol Clin 2014; 32:507. Topic 3349 Version 19.0 • All rights reserved. •

© 2017 UpToDate, Inc. Contributor Disclosures: Zahid H Bajwa, MD Grant/Research Support: Amgen [Chronic migraine (Observational study)]. Consultant/Advisory Boards: Depomed [Chronic pain (Tapentadol)]. Speaker's Bureau: Teva [Migraine (Sumatriptan iontophoretic transdermal system)]; Depomed [Migraine (Diclofenac)]; AstraZeneca [Chronic pain (Naloxegol)]. R Joshua Wootton, MDiv, PhD Nothing to disclose. Jerry W Swanson, MD, MHPE Nothing to disclose. John F Dashe, MD, PhD Nothing to disclose. Susanna I Lee, MD, PhD Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

QUESTIONNAIRE MP5(18) Part 1

Evaluation of headache in adults INSTRUCTIONS

Read through the article and answer the multiple-choice questions provided below. There is only ONE correct answer to each question.

Question 1: Which one of the following is the most common diagnosis in patients presenting to primary care physicians with headache?

A: Tension-type headache (TTH) B: Migraine C: Cluster headaches D: Secondary headache

Question 2: Which one of the following leads to significant disability?

A: Cluster headache B: Migraine C: Tension-type headache D: Secondary headache

Question 3: Which one of the following describes the classical features of a “tension-type headache?”

A: A throbbing, unilateral headache with associated nausea, vomiting, photophobia, or phonophobia

B: A mild to moderate intensity, bilateral, non-throbbing headache without other associated features

C: A severe unilateral orbital, supraorbital, or temporal headache accompanied by autonomic phenomena

D: A chronic, progressive headache without other associated features

Question 4: Which one of the following is TRUE regarding headaches?

A: Acute or chronic sinusitis is a common cause of recurrent headaches

B: Headaches commonly occur due to eye strain related to refractive errors

C: A hypertensive emergency can cause headache, but it will not present as a typical migraine or tension-type headache

D: High systolic and diastolic pressures increase the risk of nonmigrainous headache

Question 5: The examination of an adult with headache should consist of all the following, except……………………...?

A: Blood pressure and pulse B: Imaging study C: Gait examination D: Temporal and neck arteries E: Spine and neck muscles

Question 6: Which mnemonic is a reminder of danger signs (red flags) in headache?

A: DROOP B: SNOOP C: PLOD D: CLOD E: None of the above

Question 7: Which one of the following is a danger sign for the presence of serious underlying disorders that can cause headache?

A: Gradual onset headache B: Chronic anxiety C: No previous history of headache D: Headache that awakens patient from sleep

Question 8: Which one of the following should be suspected when a patient presents with headache associated with impaired vision or seeing halos around light?

A: Glaucoma B: Optic neuritis C: Raised intracranial pressure D: Pheochromocytoma

Question 9: Which of the following symptoms suggest that the headache is caused by a tumour?

A: Visual field defects B: Sudden, severe, unilateral vision loss C: Headache that is relieved with recumbency and

exacerbated with upright posture D: The presence of nausea, vomiting and worsening of

headache with changes in body position as well as an abnormal neurological examination

E: None of the above Question 10: Is it TRUE or FALSE that a positive ID migraine screen increases the pretest probability of migraine from 59% to 84% and the screen is positive when a patient answers yes to all three of the items?

A: TRUE B: FALSE

END

QUESTIONNAIRE MP5(18) Part 2

Evaluation of headache in adults INSTRUCTIONS

Read through the article and answer the multiple-choice questions provided below. There is only ONE correct answer to each question.

Question 1: In what situations should neuroimaging not be performed?

A: Focal neurologic signs or symptoms B: Onset of headache with exertion, cough, or sexual

activity C: Progressive worsening of headache despite appropriate

therapy D: Onset of headache before 40 years of age E: All the above

Question 2: Which one of the following imaging modalities is preferred for brain imaging in terms of sensitivity for intracranial pathology?

A: MRI B: CT C: Skull x-ray D: Ultrasound

Question 3: Which one of the following is FALSE regarding a “thunderclap headache?”

A: It reaches maximal intensity within a few seconds or less than one minute after the onset of pain

B: It requires urgent evaluation as such headaches may suggest subarachnoid hemorrhage and other potentially ominous etiologies

C: Causes include "orgasmic" headache associated with sexual activity and third ventricular colloid cysts

D: A lumbar puncture should be done first, followed by a head CT

Question 4: A new or recent onset headache in a patient with Lyme disease suggests which one of the following?

A: Opportunistic infection B: Intracranial tumor C: Meningoencephalitis D: Subarachnoid haemorrhage

Question 5: Which of the following is NOT TRUE with reference to chronic headache?

A: It is a specific headache type B: The term “chronic” refers to the frequency of

headaches C: “Chronic” indicates a headache frequency of 15 or

more days a month for longer than three months in the absence of pathology

D: All the above

Question 6: Which one of the following describes a “hypnic headache?”

A: It is characterized by unilateral, brief, severe attacks of pain associated with cranial autonomic features that recur several times per day

B: It is characterized by episodes of dull head pain, often bilateral, that awakens the sufferer from sleep and normally occurs after 50 years of age

C: It is characterized by a strictly unilateral, continuous headache with superimposed exacerbations of moderate to severe intensity when falling asleep

D: It is typically preceded by an episodic headache disorder that has been treated with frequent and excessive amounts of acute symptomatic medications

Question 7: Older patients are at risk for which one of the following types of headache?

A: Chronic paroxysmal hemicrania B: Trigeminal neuralgia C: Hemicrania continua D: Primary stabbing headache

Question 8: Is it TRUE or FALSE that trigeminal neuralgia may present with an insidious onset of headache, light-headedness, cognitive impairment, apathy, somnolence and occasionally seizures?

A: YES B: NO

Question 9: Which one of the following is a common cause of the onset of new or atypical headache in pregnant women?

A: Epidural hematoma B: Hypotension C: Placental abruption D: Pre-eclampsia

Question 10: Is it TRUE or FALSE that headache prevalence, duration, and severity is greater in those with more severe traumatic brain injury than with those with mild head injury?

A: TRUE B: FALSE

Question 11: Which of the following is not TRUE with reference to sinus-related pain or headache?

A: It is typically described as a pressure-like or dull sensation

B: It is usually bilateral C: It is typically associated with nasal obstruction D: It lasts for days E: It is associated with nausea, vomiting and photophobia

Question 12: Which one of the following is TRUE regarding the relationship between rhinosinusitis and headache?

A: Sinus-related pain or headache is typically described as a burning or dull sensation that is usually unilateral

B: Recurrent self-limited headaches associated with rhinogenic symptoms are most likely tension-type headaches

C: Headache associated with tachycardia and post nasal drip is likely due to rhinosinusitis

D: Headache associated with fever and purulent nasal discharge is likely rhinogenic in origin

Question 13: It is TRUE or FALSE that the initial headache evaluation should determine whether there is a potentially dangerous secondary cause of headache or whether the headache is due to one of the common types of primary headache, using the patient history as the primary diagnostic tool?

A: TRUE B: FALSE

Question 14: What difference, other than headache features and comorbidities, can guide the evaluation to help ensure appropriate diagnosis and management of headaches?

A: Patient demographics B: Patient diet C: Pain features

Question 15: Is it TRUE that headache is a frequent sequelae of mild traumatic brain injury?

A: TRUE B: FALSE

END

For office use MARK: /25= _______%

(70% PASS RATE) FAILED

(R50 to resubmit) PASSED

(IAR will be sent) MODERATED BY: CAPTURED: DATE:

PO Box 71 Wierda Park 0149

400 Theuns van Niekerk Street Wierda Park 0157

www.fohcpd.co.za Whatsapp: 074 230 3874 Tel: 012 653-0133 /2373 Mon-Fri: 07:30-16:30

This activity is accredited for TWO (2) CLINICAL CEU’S Part 1

This activity is accredited for THREE (3) CLINICAL CEU’S Part 2

PERSONAL INFORMATION (If your personal details have not changed, only complete the sections marked with an asterisk *)

ANSWER SHEET MP5(18) Part 1

Evaluation of headache in adults

MP5(18) Part 2

SEND ANSWER SHEET TO:

FAX: 086 614 4200 / 012 653 2073 OR WHATSAPP: 074 230 3874 OR EMAIL: SAFOCUS@IAFRICA.COM

YOU WILL RECEIVE A CONFIRMATION OF RECEIPT SMS WITHIN 12-24 HOURS, IF NOT RECEIVED PLEASE SEND AGAIN

Please rate the article:

HPCSA No *FOH Number

*Initials &Surname *Cell Number needed for confirmation sms

Employer Email address

*Time spent on activity _____Hour _____Min Any additional comments

A B C D E A B C D E 1 6 2 7 3 8 4 9 5 10

A B C D E A B C D E 1 9 2 10 3 11 4 12 5 13 6 14 7 15 8

I hereby declare that the completion of this document is my own effort without any assistance. Signed:

Date:

POOR 1

FAIR 2

AVERAGE 3

GOOD 4

EXCELLENT 5