Headache (Cephalgia): Symptoms, Complaints, Signs

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)
  • 80-100 %
  • 33% headache as the only symptom
Intracranial hemorrhage (cerebral hemorrhage) Sudden and severe headache (almost always)
  • 21-100 %
Transient ischemic attack (TIA) Headache
  • 15-45 %
  • 25% Headache as the main symptom
Ischemic insult (ischemic apoplexy/stroke). Headache
  • 15-40 %
Sinus vein thrombosis Headache (manifestation within the first three days after the event)
  • 50-70 %
  • 15 % Headache as the sole symptom

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)
  • Acute sinusitis (sinusitis).
  • Glaucoma (eye disease with increased intraocular pressure).
  • Hypertensive crisis (high blood pressure crisis).
  • Ischemic apoplexy
  • Meningitis (meningitis)
Chronic Chronic migraine Giant cell arteritis (RZA; arteritis temporalis
Chronic tension-type headache
  • Chronic sinusitis
  • Chronic subdural hemorrhage (hematoma) under (sub) the meninges between the dura mater and the arachnoid)
  • Sinus vein thrombosis (SVT) – occlusion of a cerebral sinus (major venous blood vessels of the brain arising from duraduplications) by a thrombus (blood clot); clinical presentation: headache, congestive papules, and epileptic seizures
  • Tumor (usually additional neurological deficits).

Differential diagnosis based on onset of headache symptomatology and maximum pain intensity

Headache onset/pain intensity Diseases Diseases with unremarkable neurological findings
Peracute/severe
  • Subarachnoid hemorrhage(SAB; thunderclap headache: about 50% of cases); onset: Seconds to a maximum of one minute
  • Pituitary apoplexy
  • Intracerebral hemorrhage (ICB); situational, headache (cough headache, sexual activity headache, airplane headache); occurring primarily in the supine position and at night
  • Epi- or subdural hemorrhage; focal deficits.
  • Vascular dissection (dissection); whiplash-like; typically unilateral.
  • Reversible cerebral vasoconstriction syndrome (RCVS); like SAB thunderclap headache.
  • Colloid cyst of the 3rd ventricle.
over hours/mean
  • Migraine
  • Arteritis temporalis; continuous headache; usually unilateral (see below Arteritis temporalis).
  • CSF negative pressure headache; standing worse than lying down.
  • Sinusitis (inflammation of the sinuses
above days/regular
  • Tension headache

Differential diagnosis based on other symptoms and findings

Symptoms/’findings Primary headache Secondary headache
Occurrence
  • Known for years
  • Sudden (acute event)/destructive pain/destructive headache (e.g., ischemia/hemorrhage).
  • Slow (e.g., malignancy)
Duration
  • Periodic/episodic
  • (Self-)limited attacks
  • Trigger factors?
  • Continuous (increasing
Medical history
  • Blank
Physical examination findings
  • Weakly or mildly pronounced disease features.
  • Conspicuous findings
Neurological deficits
  • Rarely
  • Frequent
Aura
  • Possible
  • Never
Seizures
  • Very rare
  • Frequent
Vital signs
  • Inconspicuous/stable patient

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:
      • Gait abnormalities
      • Paresis (paralysis)
      • Visual disturbances (double images!) → think of: Apoplexy (stroke) in the supply area of the posterior cerebral artery, arteritis temporalis, glaucoma, reversible posterior leukoencephalopathy (PRES).
      • Sensory disturbances and others
  • 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.