Headache

acute, new onset - Onset over seconds to hours.

Meningitis viral or bacterial	Suggested by: photophobia, fever, neck stiffness, vomiting, Kernig's sign. Petechial or purpuric rash (in meningococcal meningitis).
	Confirmed by: CT brain if neurological signs present, Lumbar puncture—Viral meningitis: CSF clear, ↑lymphocytes, ↑protein, normal glucose). Bacterial meningitis: CSF with ↑neutrophils, ↑protein, ↓glucose ± visible bacteria on gram stain.
	Management:
Low CSF pressure	Suggested by: worsening or recurrence of headache after lumbar puncture (usually for suspected meningitis) made worse by sitting up.
	Confirmed by: spontaneous resolution after few days.
	Management:
Subarachnoid haemorrhage	Suggested by: sudden occipital headache (often described as ‘like a blow to the head’), variable degree of consciousness, ± neck stiffness, subhyaloid haemorrhage, ± focal neurological signs.
	Confirmed by: CT or MRI brain scan. Lumbar puncture: blood-stained CSF that does not clear in successive bottles, presence of xanthochromia in CSF (up to 2 weeks after the haemorrhage).
	Management:.
Intracranial haemorrhage	Suggested by: focal neurological signs.
	Confirmed by: CT/MRI brain scan.
	Management:
Head injury with cerebral contusion	Suggested by: history of trauma, cuts/bruises, reduced conscious level, lucid period, amnesia.
	Confirmed by: skull X-ray, CT head normal or showing oedema but no subdual haematoma or extradural haemorrhage.
	Management:
Acute angle-closure glaucoma	Suggested by: red eyes, haloes, reduced visual acuity due to corneal clouding, pupil abnormality.
	Confirmed by: raised intra-ocular pressure.
	Management:
Sinusitis	Suggested by: fever, facial pain, mucopurulent nasal discharge, tender over sinuses ± URTI.
	Confirmed by: X-ray of sinuses or CT scan: mucosal thickening, a fluid level or opacification.
	Management:
Tension headache	Suggested by: generalised or bilateral, continuous, tight bandlike, worsens as the day progresses, associated with stress or tension, ± aggravated by eye movement.
	Confirmed by: spontaneous improvement with simple analgesia.
Bilateral migraine	Suggested by: bilateral, throbbing, ± vomiting, aura ± visual or other neurological disturbances with precipitating factor e.g. premenstrual.
	Confirmed by: resolution over hours in dark room and analgesics, helped by sleep.
	Management:

Headache—subacute onset

Onset over hours to days.

Raised intracranial pressure due to tumour, hydrocephalus, cerebral abscess etc.	Suggested by: dull headache, worse on waking, vomiting, aggravated by e.g. cough, sneezing, bending, look for papilloedema, ↑BP, ↓pulse rate, progressive focal neurological signs.
	Confirmed by: CT/MRI brain scan.
	Management:
Encephalitis	Suggested by: fever, confusion, reduced conscious level.
	Confirmed by: CSF microscopy, serology or PCR.
	Management:
Temporal/giant cell or cranial arteritis	Suggested by: scalp tenderness, jaw claudication, loss of temporal arterial pulsation, sudden loss of vision. ↑↑ESR.
	Confirmed by: temporal artery biopsy (may be done shortly after starting prednisolone).
	Management:

Headache—chronic and recurrent

Onset over weeks to months.

Tension headache	Suggested by: generalised or bilateral, continuous, tight bandlike, worsens as the day progresses, associated with stress or tension, often aggravated by eye movement.
	Confirmed by: spontaneous improvement with simple analgesia.
Migraine	Suggested by: typically unilateral, throbbing, ± vomiting, aura ± visual disturbances, precipitating factors.
	Confirmed by: resolution over hours in dark room and analgesics, helped by sleep.
	Management:
Cluster headache	Suggested by: episodic, typically nightly pain in 1 eye for weeks.
	Confirmed by: episodes resolving over hours (like migraine).
	Management:
Cervical root headache	Suggested by: occipital and back of the head, temples, vertex and frontal regions, worse on neck movement or restricted neck movements
	Confirmed by: cervical X-ray showing degenerative changes (or normal) and response to NSAIDs.
	Mangement:
Eye strain	Suggested by: headaches worse after reading. Refractory error
	Confirmed by: improvement with appropriate spectacles.
	Mangement:
Drug side effect	Suggested by: drug history (e.g. nitrates)
	Confirmed by: improvement on drug withdrawal.