Assessing Headache

Headache Management:
A Guide for Emergency Department and Primary Care Physicians


by Paul Willis, MD, neurologist, Sansum Clinic


A common symptom identified during presentation at physician office visits, headache has the potential to signify a serious condition requiring immediate attention. A systematic approach using diagnostic criteria and a simple mnemonic can help a physician distinguish between primary and secondary headaches and lead to accurate diagnosis.


Clinical Indications

When a patient presents with a headache complaint, additional symptoms indicating a potentially serious problem include: headaches associated with fever, stiff neck, nausea, and vomiting; headaches other than migraine with aura associated with focal neurologic symptoms; and headaches associated with papilledema, cognitive impairment, or personality change.


Pursuing the Cause

Migraine headaches can also be approached in a logical fashion. First recognize that migraines are wide-ranging in their presentation. Criteria set by the International Headache Society-episodic, vascular disabling headaches with accompaniments of photophobia, sonophobia, or nausea-are helpful, but other complex features or cervical tension that resembles or mimics sinus may turn out to be triptan-responsive and migrainous in retrospect.


Monitoring and charting the frequency and circumstances can help identify triggers that might encourage and guide the patient to sustain a moderate lifestyle with respect to sleep, diet, and exercise. Hormonal influences play a major role in females. Early use of triptans and anti-inflammatories might deflect the evolving headache from disabling levels. Modification of caffeine and analgesic use (opiates are best avoided except for extreme rescue) may be employed.


Preventive strategies from vitamin B2 / magnesium to prescription medications (antiseizure medications, Beta-blockers, calcium channel blockers, tricyclics, and others) are available for intractable or nonresponsive headaches. Patience and close follow-up are often required to reach satisfactory control of this surprisingly common disorder. Diagnosing physicians should recognize potential danger signs that alert us to the need to seek help for our patients. During a hectic day, a physician may be tempted to overlook the common patient complaint of headache or miss red flag presenting symptoms. However, gaining a better understanding of headache characteristics includes encouraging patients to divulge more about their headache traits, keeping in mind that it never hurts to look further into this symptom. A false negative is a far better outcome than missing a potentially life-threatening condition.


Download a treatment algorithm that complements this article  >>




•    Director's Letter
•    Rehabilitation Support
•    Radiosurgery for Sphenoid Wing Meningioma

   •     Assessing and Managing


         Headache Algorithm >>

•    Tourette Syndrome
  Cavernous Malformations

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"Snoop" Out Red Flags

The following mnemonic (SNOOP) provides a useful reminder of atypical symptoms that call for further examination when a patient presents with headache:

•    Systemic symptoms (such as fever or weight loss) or secondary risk factors (such as HIV or systemic cancer)
•    Neurologic symptoms or abnormal signs (such as confusion or impaired consciousness)
•    Onset that is sudden, abrupt, or split-second
•    Older patient (50 or older) reporting new onset and progressive headache (giant cell arthritis)
•    Previous headache history with current symptom described as a "first" of its type or a "worst" headache (change in attack frequency, severity, or clinical features)


Case Presentations

The following two cases provide disparate examples from the wide range of migraine manifestations.

Patient One 

A 35-year-old male presented for urgent care with headache. He had a 10-year history of migraine characterized by intermittent scintillating visual phenomena always in the right visual field followed by severe cervical occipital pain. Migraine accompaniments of photophobia and nausea were generally modest. Without other unusual circumstances, he described this headache as progressing to the worst he could recall. In urgent care, he received a prescription for stronger analgesics.


The next morning, he was found unresponsive. Evaluation revealed a large left occipital hemorrhage ultimately ascribed to an arteriovenous malformation (AVM). Following surgical intervention and prolonged rehabilitation, he recovered with residual right visual field deficit and seizure disorder heralded by right scintillating scotoma. He no longer experiences headaches.



Patient Two

A 50-year-old woman presented with problematic headaches that had been occurring for decades. She recalled childhood vomiting spells and menarche-onset menstrual headaches but no clear diagnostic migraine symptoms. During the next 25 years, she experienced frequent episodic sinus and cervical tension headaches. Antibiotics, decongestants and ultimately sinus surgery only modestly addressed frontal sinus pressure pain. Anti-inflammatory medications, muscle relaxants, analgesics, and chiropractic therapy were frequently employed to mitigate the cervical occipital pain.


During the patient's perimenopausal epoch, her headaches increased to near-daily frequency. She recalled her mother having "sick headaches" that seemed similar. Neurological workup was negative for any structural abnormality. She responded to triptans and, with appropriate lifestyle modification and preventive medication, remained headache-free.


Observations and Lessons

The first patient's headache—a classic migraine with aura in retrospect—resulted from a structural lesion and crossed over to the seizure venue. The two lessons to be learned from this study are that 1) migraines always presenting unilaterally should be imaged to exclude a structural lesion; and 2) a headache described as "the worst ever," even when it follows the usual pattern, calls for careful evaluation and should never be dismissed.


The second patient case shows the spectrum of migraine presentation over a lifetime: hinted at by symptoms in childhood and adolescence, unrecognized and imperfectly responded to with misdirected symptomatic treatment. The prevalence of nonspecific symptoms mimicking sinus or neck complaints is very common in migraine. Following accurate diagnosis, migraine-specific treatment may provide remarkable and gratifying improvement to quality of life.