Neuroscience Clerkship

 
 

Clinical Features that Distinguish Between Benign and Potentially Serious Underlying Causes of Headache
Headache is the one of the most common symptoms any patient sees any doctor for. Although patients are often concerned that they have some serious disorder, almost all are benign and do not indicate any structural intracranial pathology. Most headaches are migraine (and its variants) or muscle tension. However, there are certain symptoms and signs that should alert the doctor to a potentially serious cause of the headache which requires further investigation.


Also note: Headache can sometimes be a referred symptom from other anatomic structures (e.g., eye [glaucoma, uveitis, etc.]; sinus; cervical spine). In addition, fever of any cause may result in headache (presumably from vasodilatation of scalp vessels).
Symptoms of a Potentially Serious Headache
 

• Explosive onset

• Associated with Syncope

• Association with a Seizure

• Worst when Lying Down (i.e., increased intracranial pressure)

• Worst with Valsalva (e.g., coughing - results in increased intracranial pressure)

• Any Focal Neurologic Symptom, either fixed or transient (e.g., weakness, sensory loss, gait disturbance, change in personality, language disturbance, change in vision, etc.)

• Any Unusual Headache in the Elderly (possible temporal arteritis)

• Jaw Claudication (possible temporal arteritis)

• Scalp Tenderness (possible temporal arteritis)

• Progressive Worsening over days / weeks
Signs of a Potentially Serious Headache
 

• Papilledema / Retinal Hemorrhage

• Any Focal Neurologic Sign

• Markedly Elevated Blood Pressure

• Nuchal Rigidity

• Scalp Tenderness

• Fever
 

Above:  Papilledema, a ominous sign of increased intracranial pressure.
 
Disclaimer:  Note that the above lists the common potential symptoms and signs that suggest a serious headache. This list does not cover every possible serious symptoms or sign. Likewise, not every patient with one of these symptoms or signs has a serious headache. Clinical judgment is always required to determine how much investigation a patient with a headache requires.