Investigating severe headache (summary)

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This is a basic article for medical students and other non-radiologists

Investigating severe headache (cephalgia is the rarely used medical term for headache ) is a common requirement in both acute and emergency services. It is also common in neurology clinics and GP surgeries. While many of the headaches are benign a large number of patients require radiological investigation .

Worldwide, the commonest headaches are tension-type headaches and migraines (90%) . The history of tension headaches and migraines are typical and they are usually not accompanied by physical findings.

Reference article

This is a summary article; we do not have a more in-depth reference article.

Summary

  • questions
    • are there any red flags ?
      • new, different or "worst ever" headache
      • nausea/vomiting
      • altered neurology: paralysis, ataxia, abnormal pupillary response
      • early morning headaches or postural changes
      • confusion or drowsiness
      • new headaches in those over 50 years old
  • history
    • are the headaches acute, how long have the headaches been there, how long do they last, are they progressive?
    • where is the pain worst?
    • are they positional (standing/lying/moving)?
    • is there aura (photophobia/phonophobia/nausea)?
    • is there neck stiffness or fever?
  • examination
    • cranial nerve examination
    • focal signs may suggest the location of pathology
    • fundoscopy may confirm papilledema which is suggestive of raised intracranial pressure
    • visual field assessment
  • investigations
    • CT
      • used in the emergency/acute setting
      • will show hemorrhage/tumor
      • if subarachnoid hemorrhage, CT angiogram can be performed
    • MRI
      • when available, used for assessment of chronic symptoms
      • MR venogram if sinus thrombosis is suspected
  • making the request
    • know what question you are trying to answer
    • are there any red flags?
    • what is the acuity of onset?
    • how urgently does this need to be investigated?​
  • common pathology

Teaching playlist

  • severe headache playlist