Primary vs Secondary Headaches

As a general term, headache is a descriptor tied to hundreds of clinical entities. A headache is one of the most common reasons people present for medical attention. All headaches fall into 1 of 2 classification systems; primary and secondary headache syndromes. The presentation, degree of severity, underlying pathogenesis, potential clinical sequelae, management, and prognosis are as variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables as the underlying headache entities.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Definitions

  • Primary headaches: a headache (or headache disorder) not attributable to another disorder:
    • Generally benign; may be severe, recurrent, and potentially disabling
    • No dangerous underlying cause is identified. 
    • The pathophysiology is generally incompletely understood.
    • The pathophysiologic mechanisms generally involve overactivity of intracranial and extracranial nociceptors and/or related vascular structures.
  • Secondary headaches: a headache (or headache disorder) attributable to an underlying disorder:
    • May be a manifestation of an underlying systemic, vascular, or neurologic disorder
    • A potentially life-threatening etiology generally underlies the headache disorder.
    • The pathophysiology of the headache is generally related to 1 of the following:
      • Identifiable structural lesion
      • Metabolic abnormality
      • Infectious/inflammatory process

Epidemiology

  • Primary headaches: 50% of the adult population worldwide meets the clinical criteria for at least 1 primary headache disorder:
    • tension headache: approximately 40%
    • migraine headache Migraine Headache Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache: approximately 10%
    • cluster headache: approximately 1%
  • Secondary headaches: Prevalence and incidence is difficult to classify due to inconsistent documentation and coding practices among clinicians and institutions. 

Etiology

  • Primary headaches: The pathophysiologic mechanisms generally involve overactivity of intracranial and extracranial nociceptors and a complex interplay between neural and vascular structures.
  • Secondary headaches: The pathophysiologic mechanisms are generally related to an identifiable structural lesion, metabolic abnormality, or infectious/inflammatory process. 

Classification

All headaches can be classified as either primary or secondary and subclassified into a variety of classification schemes developed for clinical, epidemiologic, research, and coding purposes. The most common and clinically significant will be covered in detail here:

Primary headaches

Subtypes:

  • Migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache
  • Tension-type headache
  • Cluster headache

Frequency:

Primary headache disorders may be subclassified based on frequency of occurrence:

  • Low-frequency episodic: < 10 headache days per month
  • High-frequency episodic: 10–14 headache days per month
  • Chronic: ≥ 15 headache days per month

Secondary headaches

Subtypes:

  • Headache attributed to any of the following:
    • Head and/or cervical spine trauma
    • Cranial or cervical vascular abnormality
    • Severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Intracranial structural lesion
    • Substance use or withdrawal
    • Infection
    • Disturbance of homeostasis
    • Psychiatric disorder 
  • Headache or facial pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain attributed to: 
    • Disorder of cranial structure
    • Disorder of cervical spinal structure
    • Eyes
    • Ears
    • Nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose
    • Sinuses
    • Teeth Teeth Normally, an adult has 32 teeth: 16 maxillary and 16 mandibular. These teeth are divided into 4 quadrants with 8 teeth each. Each quadrant consists of 2 incisors (dentes incisivi), 1 canine (dens caninus), 2 premolars (dentes premolares), and 3 molars (dentes molares). Teeth are composed of enamel, dentin, and dental cement. Teeth
    • Mouth
    • Other facial or cranial structures

Etiology:

Secondary headache disorders may be subclassified based on underlying etiology:

  • Vascular
  • Infectious
  • Neoplastic
  • Metabolic
  • Other

Clinical Presentation and Diagnosis

Features of primary headaches

Features warranting a conservative clinical evaluation:

  • Known history of a primary headache syndrome
  • Similar to previous headaches
  • Absence of focal neurologic signs and symptoms
  • If present, neurologic signs/symptoms are familiar to the individual:
    • Autonomic symptoms are typical of a cluster headache.
    • Reversible neurologic deficits are common in a migraine headache Migraine Headache Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache.

“Red flag” signs and symptoms

Signs and symptoms warranting immediate workup and/or intervention:

  • Severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Focal neurologic findings
  • Papilledema
  • Neck stiffness
  • Immunocompromised state
  • Cancer/malignancy
  • 1st headache of the kind
  • Sudden (“thunderclap”) onset 
  • Mental status changes
  • Headache after trauma
  • Headache with visual changes
  • New-onset seizure
  • Exertional headache

Comparison of primary headaches

Table: Primary headache entities
Clinical entity Historical clues/risk factors Clinical features
Tension headache
  • Bilateral location
  • Mild-to-moderate intensity
  • Tight or squeezing quality
  • Associated with extracranial muscle tenderness, trigger points
  • Affects almost everyone at some point in a lifetime
  • Often self-diagnosed and self-managed
  • Generally responds to simple and compound analgesics
  • Can be managed by primary care
Migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache headache
  • Unilateral > bilateral
  • Moderate-to-severe intensity
  • Women > men
  • Pulsatile quality
  • Associated with prodrome, aura, and postdrome
  • Associated with nausea, photophobia, and phonophobia
  • Associated with triggers
  • May present with transient neurologic and/or visual symptoms
  • May cause significant quality of life impairment and work-related disability
  • Onset during childhood or puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty (women), wanes during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, and persists until menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause
  • May need consultation by a specialist to formulate an effective abortive and preventative strategy
Cluster headache
  • Unilateral location
  • Severe intensity
  • Men > women
  • Associated with smoking/alcohol abuse
  • Accompanied by ipsilateral autonomic symptoms
  • May experience several severe episodes per day
  • May cause significant quality of life impairment and work-related disability
  • Also known as “ suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide headaches” due to the increased risk of suicidal thoughts during an attack
  • May need consultation by a specialist to formulate an effective abortive and preventative strategy

Comparison of common secondary headaches

 The following tables outline the most important secondary headaches based on their etiology.

Table: Vascular etiologies of high risk headaches
Clinical entity Historical clues/risk factors Clinical features
Subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH) ( SAH SAH Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH))
  • Sudden onset
  • Severe intensity at onset
  • Syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope/near syncope
  • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain/stiffness
  • Diplopia
  • Meningeal signs
  • Nausea and vomiting
Reversible cerebral vasoconstriction syndrome (RCVS)
  • Sudden onset
  • Severe intensity at onset
  • Short duration
  • Recurrent
  • Associated with triggers
  • Transient neurologic deficits from vasospasm
  • Neurologic deficits may persist (if vasospasm persists)
Cervical artery dissection/vertebral artery dissection
  • Associated with head and/or neck trauma
  • Prominent neck pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • New-onset dizziness
  • New-onset tinnitus
  • Cranial nerve palsy:
    • Nystagmus
    • Horner syndrome Horner syndrome Horner syndrome is a condition resulting from an interruption of the sympathetic innervation of the eyes. The syndrome is usually idiopathic but can be directly caused by head and neck trauma, cerebrovascular disease, or a tumor of the CNS. Horner Syndrome
  • Cervical artery bruit
  • Presents with cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke/ transient ischemic attack Transient ischemic attack Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) ( TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA))
Cerebral vein thrombosis/dural sinus thrombosis
  • Hypercoagulable Hypercoagulable Hypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States state/risk factors
  • Pregnancy
  • Postpartum
  • Neurologic deficits inconsistent with arterial ischemia
  • Associated with seizure
  • Papilledema on fundoscopy
  • Encephalopathy
Subdural hematoma/epidural hematoma
  • Associated with head trauma Head trauma Head trauma occurs when external forces are directed to the skull and brain structures, resulting in damage to the skull, brain, and intracranial structures. Head injuries can be classified as open (penetrating) or closed (blunt), and primary (from the initial trauma) or secondary (indirect brain injury), and range from mild to severe and life-threatening. Head Trauma
  • Anticoagulant therapy
  • Gradual progression of neurologic deficit and/or mental status
  • Posterior fossa hematoma →
    • Nausea/vomiting
    • Visual changes
    • Ataxia
    • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
    • Anisocoria
    • Nuchal rigidity
Intraparenchymal hemorrhage (IPH)
  • Sudden onset
  • Associated with severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Anticoagulant therapy
Variable presentation depending on site of bleed (much like cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke/ TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA))
Idiopathic intracranial hypertension Idiopathic Intracranial Hypertension Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a clinical disorder that presents with symptoms due to increased intracranial pressure (ICP; ≥ 20 mm Hg) or CSF pressure (> 250 mm H2O), with no structural changes or other attributable causes. Idiopathic Intracranial Hypertension
  • Overweight/obese women
  • Childbearing age
  • Transient/intermittent visual symptoms
  • Papilledema on fundoscopy
  • Abducens nerve palsy
  • Other cranial nerve palsies
  • Visual deficit
  • Tinnitus
Spontaneous intracranial hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Severe headache in upright position
  • Headache improves with caffeine and while lying flat
  • Headache worsens with Valsalva maneuver
  • Common after dural puncture
  • Neurologic findings may be absent or widely variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables
  • Tinnitus
  • Cervical pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Nausea and vomiting
Giant-cell arteritis
  • Age > 50 years
  • Sudden-onset visual disturbances (often monocular)
  • Jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint claudication
  • Palpable or nodular temporal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Elevated acute-phase reactants:
    • CRP
    • Erythrocyte sedimentation rate (ESR)
Hypertensive encephalopathy
  • Gradual-onset headache in the setting of severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Altered mental status
  • Severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Papilledema and retinal hemorrhage on fundoscopy
  • Hematuria and proteinuria on urinalysis
  • Encephalopathy
Posterior reversible encephalopathy syndrome
  • Gradual-onset headache inconsistently associated with severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Nausea and vomiting
  • Visual changes
  • Pregnancy or postpartum period
  • Hypertension may or may not be present
  • Papilledema and retinal hemorrhage on fundoscopy
  • Hematuria and proteinuria on urinalysis
  • Encephalopathy
Table: Infectious etiologies of high-risk headaches High-Risk Headaches High-risk headaches, sometimes also referred to as red-flag headaches, encompass secondary causes of headache that can result in irreversible end-organ damage, neurologic deficits, loss of vision, and even death. Entities such as subarachnoid hemorrhage, meningitis/encephalitis, and intracranial tumors carry high morbidity and mortality risks if not recognized and treated immediately. High-Risk Headaches
Clinical entity Historical clues/risk factors Clinical features
Meningitis and/or encephalitis Encephalitis Encephalitis is inflammation of the brain parenchyma caused by an infection, usually viral. Encephalitis may present with mild symptoms such as headache, fever, fatigue, and muscle and joint pain or with severe symptoms such as seizures, altered consciousness, and paralysis. Encephalitis
  • Toxic-appearing
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain/stiffness
  • Altered mental status/level of consciousness
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Meningism
  • Altered mental status/level of consciousness
  • Seizure
  • Cranial nerve palsies
  • Petechiae or purpura
Brain abscess Brain abscess Brain abscess is a life-threatening condition that involves the collection of pus in the brain parenchyma caused by infection from bacteria, fungi, parasites, or protozoa. The most common presentation is headache, fever with chills, seizures, and neurological deficits. Brain Abscess
  • Onset of headache may be sudden or gradual
  • Recent history of infection:
    • Direct spread ( sinusitis Sinusitis Sinusitis refers to inflammation of the mucosal lining of the paranasal sinuses. The condition usually occurs concurrently with inflammation of the nasal mucosa (rhinitis), a condition known as rhinosinusitis. Acute sinusitis is due to an upper respiratory infection caused by a viral, bacterial, or fungal agent. Sinusitis, otitis)
    • Distant spread ( endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis, bacteremia)
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever may be variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables
  • Neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain/stiffness may be variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables
  • Papilledema on fundoscopy
  • Insidious onset of focal neurologic deficits or cranial nerve palsies
Table: Neoplastic etiologies of high-risk headaches High-Risk Headaches High-risk headaches, sometimes also referred to as red-flag headaches, encompass secondary causes of headache that can result in irreversible end-organ damage, neurologic deficits, loss of vision, and even death. Entities such as subarachnoid hemorrhage, meningitis/encephalitis, and intracranial tumors carry high morbidity and mortality risks if not recognized and treated immediately. High-Risk Headaches
Clinical entity Historical clues/risk factors Clinical features
Brain tumor
  • Cancer
  • Headache worsens with cough, Valsalva maneuver
  • Insidious headache onset, but may be sudden if tumor bleeds
  • Nausea and vomiting
  • Papilledema on fundoscopy
  • Seizure
  • Altered mental status/level of consciousness
  • Neurologic deficits corresponding to tumor location
Colloid cyst of 3rd ventricle
  • Headache worsens in upright position, improves with lying flat
  • Altered mental status
  • Symptoms may fluctuate
  • Altered mental status
  • Diplopia
  • Memory issues
  • Vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo
Pituitary apoplexy
  • Associated with pituitary tumors (most often benign)
  • Sudden-onset headache associated with infarction/bleeding into tumor
  • Nausea and vomiting
  • Altered mental status
  • Visual/oculomotor defect
  • Endocrine dysfunction
Table: Other etiologies of high-risk headaches High-Risk Headaches High-risk headaches, sometimes also referred to as red-flag headaches, encompass secondary causes of headache that can result in irreversible end-organ damage, neurologic deficits, loss of vision, and even death. Entities such as subarachnoid hemorrhage, meningitis/encephalitis, and intracranial tumors carry high morbidity and mortality risks if not recognized and treated immediately. High-Risk Headaches
Clinical entity Historical clues/risk factors Clinical features
Acute narrow-angle glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
  • Ocular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Ocular injection
  • Loss of vision
  • Nausea and vomiting
  • Conjunctival injection
  • Corneal clouding; fixed
  • Pupillary dilation with lack of constriction
  • Elevated intraocular pressure
CO toxicity
  • Acute CO exposure
  • Headache improves with separation from CO
  • Nausea/vomiting
  • Light-headedness/dizziness
  • Fatigue/malaise
  • Seizure
  • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
  • Red macula on fundoscopy
Preeclampsia/eclampsia
  • Pregnant woman at > 20 weeks
  • Sudden-onset headache associated with blood pressure > 140/90 mm Hg
  • Tinnitus
  • Visual disturbance
  • Seizure
  • Proteinuria
  • Brisk deep tendon reflexes (DTRs)
  • Placental abruption
  • Symptoms abate on delivery of the fetus

Diagnosis

Laboratory evaluation

  • Basic lab studies may be warranted with the initial headache workup:
    • CBC
    • Basic metabolic panel (BMP) or comprehensive metabolic panel (CMP)
    • Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies: PT, INR, PTT
  • Basic and specific lab studies may be indicated for secondary headache evaluation:
    • CRP
    • Erythrocyte sedimentation rate (ESR)
    • Hormone levels
    • CSF studies:
      • Cell count
      • Protein
      • Glucose
      • Gram stain
      • Opening pressure

Neuroimaging evaluation

  • Primary headache syndromes generally do not require neuroimaging for diagnosis; however, neuroimaging may be useful to:
    • Rule out secondary causes of headache at the initial evaluation
    • Evaluate headache severity or clinical features atypical of the individual
    • Evaluate neurologic signs or symptoms present with primary headaches (e.g., autonomic phenomena of cluster headache or focal neurologic phenomena of migraine headache Migraine Headache Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache)
  • Head CT without contrast is generally recommended as the initial imaging test of choice if “red flag” signs or symptoms are present.

Management

A wide range of management strategies exist for the various primary and secondary headache disorders. Only a broad overview is presented:

Primary headaches

Pharmacological management:

Most primary headache episodes and/or disorders are managed conservatively:

  • Simple or compound oral analgesics to abort isolated headache attacks:
    • Simple analgesics (single ingredient, nonspecific mechanism of action):
      • Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen
      • NSAIDs
    • Compound analgesics (more than 1 ingredient, nonspecific mechanism of action):
      • Aspirin + butalbital + caffeine
      • Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen + NSAID NSAID Nonsteroidal antiinflammatory drugs (NSAIDs) are a class of medications consisting of aspirin, reversible NSAIDs, and selective NSAIDs. NSAIDs are used as antiplatelet, analgesic, antipyretic, and antiinflammatory agents. Nonsteroidal Antiinflammatory Drugs +/- caffeine, butalbital, or codeine
  • Specialized-mechanism or disease-specific analgesics to abort isolated headache attacks:
    • Triptans Triptans Triptans and ergot alkaloids are agents used mainly for the management of acute migraines. The therapeutic effect is induced by binding to serotonin receptors, which causes reduced vasoactive neuropeptide release, pain conduction, and intracranial vasoconstriction. Triptans and Ergot Alkaloids for migraine and cluster headaches Cluster headaches Cluster headache is a primary headache disorder characterized by moderate-to-severe unilateral headaches that occur in conjunction with autonomic symptoms. Cluster headache can last from weeks to months, during which the affected individual may experience attacks up to several times a day, followed by a pain-free remission period. Cluster Headaches
    • Calcitonin gene-related peptide (CGRP) inhibitors for migraines
    • O₂ delivery at 100% for cluster headaches Cluster headaches Cluster headache is a primary headache disorder characterized by moderate-to-severe unilateral headaches that occur in conjunction with autonomic symptoms. Cluster headache can last from weeks to months, during which the affected individual may experience attacks up to several times a day, followed by a pain-free remission period. Cluster Headaches

Prevention:

Multiple preventative headache regimens exist for primary headache syndromes:

  • Antihypertensives
  • Antidepressants
  • Anticonvulsants
  • Botulinum toxin
  • Specialized-mechanism or disease-specific interventions to prevent/reduce headache attack frequency:
    • Monoclonal antibody regimens
    • CGRP inhibitors for migraines
    • Interventional nerve blocks/ablations to targeted nerve structures

Secondary headaches

Secondary headache syndromes may require emergent evaluation and management strategies by consultation from 1 or more specialists:

  • Neurosurgical consultation
  • Interventional radiology/vascular intervention consultation
  • Neurology consultation
  • Ophthalmology consultation
  • HEENT surgical consultation
  • Infectious disease consultation
  • Medical/surgical oncology consultation

The clinician should look for the “hidden” cause of secondary headache (medication-overuse headache):

  • The individual generally has a primary headache disorder.
  • The primary headache attack frequency generally qualifies as frequent or chronic.
  • The individual has developed a pattern of overuse, misuse, or abuse of abortive medications.
  • A 2nd, “rebound” headache entity (or disorder) has developed and is difficult to distinguish from the primary headache.

References

  1. Hainer, B., Matheson, E. (2013). Approach to Acute Headache in Adults. American Family Physician. 87(10), 682–687. Retrieved August 15, 2021, from https://www.aafp.org/afp/2013/0515/p682.html
  2. Beck, E. (2013). Hard-to-Diagnose Headache: Practical Tips for Diagnosis and Treatment. American Family Physician. 87(10), 672–673. Retrieved August 15, 2021, from https://www.aafp.org/afp/2013/0515/p672.html
  3. Headache Classification Committee of the International Headache Society (IHS). (2013). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 33(9), 629–808. Retrieved August 15, 2021, from https://doi.org/10.1177/0333102413485658

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details