1. 
   

   Are there warning signs of a secondary headache that would require further imaging?

   
   
2. 
   

   Is the headache new or different?

   
   
3. 
   

   Is the headache brought on by exertion, sexual intercourse, coughing, or sneezing?

   
   
4. 
   

   Is the onset of the headache sudden or severe?

   
   
5. 
   

   Has the patient experienced antecedent head or neck trauma?

   
   
6. 
   

   Does she have any neurologic symptoms other than visual symptoms occurring only at the beginning of the headache syndrome?

   
   
7. 
   

   The patient described her typical migraine headaches.

Complaints of headache represent a major health problem due to their prevalence, chronicity, and the cost of ruling out life-threatening or serious underlying pathology that may cause significant morbidity and mortality. Up to 4.5% of all emergency department visits may be attributed to symptoms of headache, and headache may be the fifth most common reason for primary care visits (following checkups, upper respiratory illnesses, back pain, and skin rashes). Loss of productivity due to headache is also substantial with an estimated cost of billions of dollars.

The International Headache Society classifies headache as primary and secondary. Primary headaches account for at least 90% of all headaches and have benign outcomes. Primary headaches include migraine with or without aura, tension type headache, and less commonly, cluster headache. Some patients with a history of primary headaches have significant risk factors for developing secondary headaches. This chapter focuses on the diagnostic approach for the patient with headache in the hospital, and the reader is referred to subsequent chapters for specific management.

Secondary headaches may be either one of the presenting symptoms leading to admission or acquired secondary to a diagnostic or therapeutic intervention. Rarely, the initial presentation of a primary headache syndrome may occur in the hospital. For patients with preexisting headache syndromes, it is important to recognize that there may be significant drug interactions between medications used to treat chronic headache and those used to treat systemic disease, and there are also important contraindications to commonly used migraine medications that may limit the safety of these drugs in hospitalized patients.

Elucidating the cause of a headache, particularly when severe, requires an understanding of the pathophysiology of the major headache types and recognizing the classic types of pain syndromes (and associated symptoms) they produce. Primary headaches should not cause focal neurologic signs and symptoms, except sometimes briefly during the aura phase of a complex migraine.

Migraine

In general, migraine causes episodic severe headache pain associated with nausea, photophobia, and photophobia insensitivities to external stimuli. This disorder is typified as much by nausea and photophobia as it is by pain. Because of the severity of pain associated with migraines, it is the most common headache that leads patients to medical attention (even though it is not nearly as common as tension headaches). Environmental or physiologic stimuli trigger recurrent and stereotyped headache spells that may be associated with meningeal symptoms and signs. Many patients will describe an aura or warning beforehand. A history of recurrent headaches, similar in severity and character occurring with weather changes, the menstrual cycle, stress, sleep deprivation, excessive sleep, withdrawal from caffeine, or associated with ingestion of certain types of food are often migrainous headaches (Table 87-1). Migraine runs in families and can be associated with mitral valve prolapse. The precipitating etiology is probably electrical, much like seizures, rather than vasoconstriction followed by vasodilatation as previously thought.

In general, the most important question to answer when considering migraine is whether the patient has ever had a headache like this before. The classic question about the severity of headache—the worst headache ever—does not help distinguish between primary and secondary headache because every migraine sufferer will have the worst migraine of her life at some point, and the most severe headaches are more likely to trigger medical consultation. The evolution of symptoms may help distinguish migraine from other causes of neurologic deficit. Classically migraines begin mildly, following an aura, and worsen over minutes to hours to reach a pinnacle of pain. Patients can often predict when they are about to get a headache as they begin to feel ill or have mild photophobia as the symptoms begin to worsen over time. The pain is not maximal at onset.

At the bedside patients will often exhibit significant photophobia and complain of nausea, although not always with vomiting. They will often have some neck stiffness. While it is true that migraines can occasionally present with focal neurological findings (termed complex migraines when such focal findings exist), it is best to assume that patients with severe headache and focal neurologic findings have something more ominous until proven otherwise.

Tension or Muscle Contraction Headaches

These are usually due to tension or a spasm within the pain-sensitive muscles of the neck or temples. Tension headaches are a muscular pain syndrome similar to a strained muscle in any other portion of the body (Table 87-2).

Patients with muscle contraction pain due to tight muscles in the neck, tension from grinding the jaw, or chronic stress can have a different history and physical than any other headache type. In general, tension headaches or muscle contraction headaches do not have associated photophobia, phonophobia, nausea, or vomiting. They tend to be unilateral or bilateral aching pain and worsen with stress. They are usually not disabling.

Cluster Headaches

Cluster headaches abruptly reach maximum intensity on one side of the head, last 1 to 2 hours, and have associated ipsilateral autonomic signs such as tearing, miosis, ptosis, or rhinorrhea. Patients should not have focal neurologic signs or symptoms (Table 87-3).

History

“Do Not Miss Headaches”

While the vast majority of headache pain may have benign causes, a small percentage may be “sentinel events” heralding dangerous and life-threatening sequelae. Secondary headaches result from underlying diseases that require further evaluation and treatment on an emergent basis (Table 87-4).