Cephalgia (headache) may present in the following ways:
- Short-lasting vs. long-lasting pain.
- Sharp vs. dull
- Unilateral vs. bilateral
- Improvement vs. deterioration due to movement
The following accompanying symptoms may occur:
- General feeling of illness
- Neck pain
- Nausea (nausea)/vomiting
- Vertigo (dizziness)
- Visual disturbances
- Photophobia (light shyness)
- Sensitivity to noise
- Red, watery eyes
Notice:
- Actively look for warning signs (SNOOP: see below; red flags; see below).
- Secondary headache, i.e. symptomatic headache as a manifestation of another disorder. are unlikely in the absence of red flags. Note: Symptomatic headaches are significantly less common than idiopathic headaches (= headaches that are themselves the disease), at about 8%.
Cerebrovascular events and their headache prevalence (headache frequencies).
Cerebrovascular event | Headache | Headache prevalence |
Subarachnoid hemorrhage (SAB) | acute annihilation headache (primary thunderclap headache) |
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Intracranial hemorrhage (cerebral hemorrhage) | Sudden and severe headache (almost always) |
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Transient ischemic attack (TIA) | Headache |
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Ischemic insult (ischemic apoplexy/stroke). | Headache |
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Sinus vein thrombosis | Headache (manifestation within the first three days after the event) |
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Differential diagnosis based on the onset of headache symptomatology
Start | Primary headache | Secondary headache |
Apoplectiform | Idiopathic thunderclap headache (max intensity in <1 minute; lasts 1 hour to 10 days) | Subarachnoid hemorrhage (SAB; hemorrhage between the spider meninges and the soft meninges; thunderclap headache: about 50% of cases) |
(Idiopathic) benign stabbing headache | Dissection (splitting of the wall layers of, for example, an artery) | |
Trigeminal neuralgia (sudden onset, tearing, and burning pain) | ||
Subacute | Tension-type headache | Ischemic apoplexy |
Migraine attack | Intracerebral hemorrhage (ICB; cerebral hemorrhage). | |
Trigeminal autonomic headache: cluster headache; paroxysmal hemicrania (headache disorder characterized by strictly unilateral attacks of pain); SUNCT syndrome (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing); hemicrania continua (persistent, strictly unilateral continuous headache) |
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Chronic | Chronic migraine | Giant cell arteritis (RZA; arteritis temporalis |
Chronic tension-type headache |
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Differential diagnosis based on onset of headache symptomatology and maximum pain intensity
Headache onset/pain intensity | Diseases | Diseases with unremarkable neurological findings |
Peracute/severe |
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over hours/mean |
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above days/regular |
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Differential diagnosis based on other symptoms and findings
Symptoms/’findings | Primary headache | Secondary headache |
Occurrence |
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Duration |
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Medical history |
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Physical examination findings |
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Neurological deficits |
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Aura |
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Seizures |
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Vital signs |
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The SNOOP scheme
Under the acronym SNOOP, the American Headache Society has compiled simple warning signs (“worrisome headache red flags”) that may indicate a serious condition:
S: Systemic symptoms | Fever, weight loss, orsecondary risk factors (HIV, systemic cancer/B-symptomatic* ). |
N: Neurologic symptoms or abnormal signs. | Loss of consciousness, impaired vigilance, vigilance disorder, speech disorder, focal neurologic deficits |
O: “onset.” | explosive onset with reaching the punctum maximum (p.m.).within 1 minute, annihilation pain/ thunderclap headache |
O: “Older”) (age). | New event and progressive headache, especially in middle age >50 years (giant cell arteritis); higher risk of “true” brain disease such as apoplexy (stroke) |
P: Previous headache history. | First headache or change in headache pattern (change in attack frequency, severity or clinical features) |
* B symptomatology
- Unexplained, persistent, or recurrent fever (>38 °C).
- Night sweats (wet hair, soaked sleepwear).
- Unwanted weight loss (> 10% percent of body weight within 6 months).
Warning signs (red flags) of secondary headache
- Anamnestic information:
- Young woman + migraine with aura and high attack frequency + smoking + hormonal contraception with estrogens → think of: Apoplexy
- Pregnancy (especially 3rd trimester/third trimester) → think of: EPH-gestosis (impending eclampsia, i.e., most severe manifestation of gestosis accompanied by seizure or profound unconsciousness).
- Age
- < 3-5 years → think of: Macrocephalus (head circumference > 97th percentile based on age and sex (or > 2 SD))? Physical therapy as an indication of developmental delays?
- <10 years + new onset headache → think of: symptomatic causes.
- > 50 years + new-onset headache; regardless of location → think of: Giant cell arteritis (arteriits temporalis).
- > 50 years + new-onset headache + change or unusual cluster of pre-existing primary headache* → think: symptomatic causes
- Time of day: regular nocturnal headache → think of: Brain tumor
- Localization: severe occipital headache (belonging to occiput) → think of: Brain tumor
- Duration: less than 8 weeks → think of: Brain tumor
- Infection: infection-associated headache (most common symptomatic headache).
- New-onset headache in known malignancy (tumor disease) or HIV infection.
- Acute first-ever headache or first-ever headache of this severity → think of: Brain tumor
- Trauma: post-traumatic headache
- Changes in character → think of: Brain tumor
- Reinforcement by coughing → think of: Brain tumor
- Morning fasting vomiting → think of: Brain tumor
- Newly increasing headache with fasting vomiting → think of: increased intracranial pressure (pay attention to other signs of intracranial pressure: e.g. papilledema (swelling (edema) at the junction of the optic nerve with the retina, which is noticeable as a protrusion of the optic nerve head; congestion papilla i. R. bilateral).
- Change of a long pre-existing headache.
- Nightly awakening due to headache
- Medication or drug use
- Sudden onset headache → think of: Exertional headache or intracerebar hemorrhage (brain bleed).
- Elevated temperatures → think of: Meningitis (meningitis)/meningoencephalitis (combined inflammation of the brain (encephalitis) and meninges (meningitis)).
- Massively elevated blood pressure → think of: hypertensive crisis.
- General symptoms such as aching limbs, weight loss → think of: Arteritis temporalis
- Peracute onset (annihilation headache, < 1 min) – exclusion of acute neurologic disease (e.g., subarachnoid hemorrhage, SAB (hemorrhage between the spider meninges and soft meninges); posterior reversible encephalopathy syndrome) required; other differential diagnoses include:
- Carotid dissection – splitting of the intima and media of the carotid artery due to hemorrhage.
- Primary cerebral angiitis
- Reversible cerebral vasoconstriction syndrome (RCVS): disease that typically affects middle-aged women and occurs in association with the use of adrenergic or serotinergic agents. In addition to annihilation headache, multiple and multilocular vasospasms (vasospasms of vessels) occur on cerebral angiography (imaging technique for visualizing arteries and veins using contrast media)
- Long-lasting, progressive headache → think of: Temporal arteritis, sinus vein thrombosis (SVT; occlusion of cerebral vessels by a blood clot), tumor
- Repeated vomiting
- Progressive (progressive), refractory headaches
- Meningismus (painful neck stiffness) → think of: SAB
- New onset of neck/neck pain/retroorbital (“behind the eye socket”) pain → think of: Aortic dissection (synonym: aneurysm dissecans aortae) – acute splitting (dissection) of the wall layers of the aorta (main artery), with a tear of the inner layer of the vessel wall (intima) and hemorrhage between the intima and the muscular layer of the vessel wall (outer media), in terms of an aneurysm dissecans (pathological expansion of the artery).
- Exanthem (skin rash) → think of: Coxsackie infection, HIV, relapsing fever, sleeping sickness (African trypanosomiasis), Sindbis fever, syphilis, trichinosis, vasculitis, viral hemorrhagic fever.
- Neurological abnormalities* : → think of: EPH-gestosis (eclampsia), intracerebral hemorrhage (ICB), brain tumor, ischemic apoplexy (stroke), meningoencephalitis, sinus vein thrombosis (SVT), subarachnoid hemorrhage (SAB), subdural hematoma (SDH; hematoma) under (sub) the hard meninges between the dura mater and arachnoid).
- Epileptic seizures
- Alteration of consciousness
- Neurological deficits:
- Paralysis, congestive papillae and the symptom complex of disorientation, memory loss, somnolence and unconsciousness.
- Unclear visual field loss → think of: Brain tumor
* Indications – without marking accompanying general symptoms – for a secondary headache syndrome.