Differential Diagnosis Of Headache , Determining Cause on the basis of History, Physical Examination and Investigations
Although extremely common, headache should always be investigated if there is any concern regarding sinister pathology, such as CVA or malignancy.Temporal arteritis must be treated immediately withhigh-dose corticosteroids to avoid complete and irreversible blindness.
● Subarachnoid haemorrhage
● Intracranial haemorrhage/infarction
● Systemic infection
● Acute angle-closure glaucoma
CHRONIC OR RECURRENT HEADACHE
● Tension headache
● Cluster headaches
● Drugs, e.g. glyceryl trinitrate, nifedipine, substance
withdrawal (especially alcohol)
● Cervical spondylosis
● Psychological (including anxiety and depression)
● Raised intracranial pressure
● Cerebral abscess
● Benign intracranial hypertension
● Temporal arteritis
● Paget’s disease of bone
● Severe hypertension
● Carbon monoxide poisoning
Sudden onset of severe pain is usually due to a vascular cause,
especially subarachnoid haemorrhage from a ruptured berry
aneurysm. Cluster headache and migraine intensify over minutes and
may last several hours, while meningitis tends to evolve over hours to
days. Progressive severe headaches that develop over days or weeks
should lead to the consideration of raised intracranial pressure from
tumour or chronic subdural haemorrhage. The onset of headache
may be preceded by an aura with migraine.
Classically, headache from migraine is unilateral. Temporal arteritis
leads to more localised pain over the superficial temporal arteries
that can be accompanied by jaw claudication. Ocular pain is
experienced with glaucoma, and retro-orbital pain with cluster
The intensity of pain contributes little when discriminating between
the causes; however, the character of the pain may be useful.
Patients with tension headache often complain of a tight band-like
sensation; this is in contrast to the pain experienced with raised
intracranial pressure, which is often reported to have a bursting
quality. Migraine-related and temporal arteritis headaches have a
Headache originating from raised intracranial pressure is precipitated
by changes in posture, coughing or sneezing, and is often worse in
the mornings. Photophobia may be experienced by patients suffering
with migraine, meningitis or glaucoma. They may prefer to lie in a
darkened room when headaches arise. Certain foods such as cheese,
red wine and chocolate are known to precipitate migraine. It is
very common for headache to be precipitated by systemic illnesses
such as a cold or influenza. Headache precipitated by touch occurs
with superficial temporal artery inflammation from temporal
arteritis. A drug history may elucidate the relationship between
the administration of drugs with headache as a side-effect, such as
glyceryl trinitrate and nifedipine. Alternatively, headache can also
result from substance withdrawal in substance-dependent patients.
Neck stiffness (meningism) is experienced with both meningitis
and subarachnoid haemorrhages. Visual disturbances in the form
of haloes occur with glaucoma. Flashing lights and alternations
in perception of size may be reported by patients suffering with
migraine, and this may be accompanied by photophobia, nausea
and vomiting. Transient neurological deficits may also occur.
However, progressive neurology associated with headache is
more suggestive of an intracranial space-occupying lesion, such as
haemorrhage, abscess and tumour. Unilateral visual loss may result
as a complication of temporal arteritis, and this may be accompanied
by proximal muscle pain, stiffness and weakness or tenderness.
Conjunctival infection is experienced with both glaucoma and
cluster headaches, along with lacrimation, which is a feature of the
latter. With normal pressure hydrocephalus in adults, headaches are
associated with dementia, drowsiness, vomiting and ataxia.
Pyrexia may indicate the presence of systemic infection, meningitis
An assessment of the conscious state should be undertaken and
quantified on the GCS. Impairment of consciousness is a sign of
a serious underlying aetiology, such as meningitis, subarachnoid
haemorrhage and raised intracranial pressure. Inspection of the
eyes may reveal conjunctival infection with glaucoma and cluster
headaches during an acute attack. With acute angle-closure
glaucoma, the cornea is hazy and the pupil fixed and semi-dilated.
Petechial haemorrhages classically occur with meningococcal
Tenderness along the course of the superficial temporal artery, with
absent pulsation, is consistent with temporal arteritis.
A detailed neurological examination is performed to identify
the site of any structural lesion. Unilateral total visual loss can be
precipitated by temporal arteritis due to ischaemic optic neuritis.
Visual field defects (hemianopia) can be caused by contralateral
lesions in the cerebral cortex. Fundoscopy is performed to identify
papilloedema from raised intracranial pressure.
Transient hemiplegia can occur with migraine, but progressive
hemiplegia is more indicative of a space-occupying lesion, such as a
tumour or intracranial haemorrhage. Neck stiffness is a feature of
both meningitis and subarachnoid haemorrhage. With meningitis,
Kernig’s sign (pain on extending the knee with the hip in a flexed
position) may be present.
WCC ↑ meningitis, cerebral abscess and systemic infection.
ESR and CRP
↑ temporal arteritis, infection, intracranial bleeding.
Hypertensive headaches with renal disease.
Elevated in Paget’s disease.
Cervical spine X-rays identify cervical spondylosis and cranial
X-rays may reveal Paget’s disease.
In most cases, the diagnosis can be made on clinical assessment.
Features in the history and examination may guide specific
With meningitis, systemic infection.
Visualisation of the anatomical structures in the cranium is
very useful in the presence of neurological deficit. Cerebral
tumours may be visualised as high or low-density masses.
Intracranial bleeding can be identified as areas of high density
during the first two weeks. An extradural haematoma presents
as a lens-shaped opacity, and subdural haematoma presents
as a crescent-shaped opacity. After two weeks, intracranial
haematomas become isodense and more difficult to visualise.
Following subarachnoid haemorrhage, blood may be visualised
in the subarachnoid space. Occasionally the offending aneurysm
or arteriovenous malformation may be imaged. Enlargement of
the ventricles may be an indication of hydrocephalus. Contrastenhanced
CT or MRI will increase the sensitivity to diagnose
A lumbar puncture may be undertaken following the exclusion
of raised intracranial pressure, when there is suspicion of
meningitis or subarachnoid haemorrhage. The opening pressure
is recorded and the CSF obtained is inspected for consistency
and colour. The consistency of the CSF is turbid with meningitis,
and yellow staining of the CSF (known as xanthochromia)
occurs with subarachnoid haemorrhage, owing to breakdown
of haemoglobin from red blood cells. The CSF is then sent
for microscopy, culture, cytology and biochemical analysis
for glucose and protein. An abnormal increase in white cells
may be seen on microscopy with meningitis. With bacterial or
tuberculous meningitis, the glucose is low and protein content
high. With viral meningitis the glucose content is normal and
protein content mildly elevated. A lumbar puncture may also be
helpful in cases of benign intracranial hypertension.
Temporal artery biopsy
Inflammation and giant cells may be seen with temporal
arteritis. A normal biopsy does not, however, exclude the
disease, as there may be segmental involvement of the temporal
Intraocular pressure measurements
Tonometry will reveal high intraocular pressures with glaucoma.
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