Warning Symptoms and Signs of a Serious Disorder
- Scalp tenderness, weight loss, pain with chewing, muscle pains, or malaise in patients at least 55 years of age (GCA).
- Optic nerve swelling.
- Fever.
- Altered mentation or behavior.
- Stiff neck.
- Decreased vision.
- Neurologic signs.
- Subhyaloid (preretinal) hemorrhages on fundus examination.
Suggestive Symptoms and Signs
- Onset in a previously headache-free individual.
- A different, more severe headache than the usual headache.
- A headache that is always in the same location.
- A headache that awakens the person from sleep.
- A headache that does not respond to pain medications that previously relieved it.
- Nausea and vomiting, particularly projectile vomiting.
- A headache followed by migraine-like visual symptoms (abnormal time course of events).
Workup- History: Location, intensity, frequency, possible precipitating factors, and timing? Determine age of onset, exacerbating/relieving factors, and whether there are any associated signs or symptoms. Specifically ask about concerning symptoms and signs listed above. Also ask about trauma, medications including birth-control pills, personal or family history of migraine, and motion sickness or cyclic vomiting as a child?
- Complete ocular examination, including pupillary, motility, and visual field evaluation; intraocular pressure measurement, optic disc and venous pulsation assessment, and a dilated retinal examination. Manifest and cycloplegic refractions may be helpful.
- Neurologic examination (check neck flexibility and other meningeal signs).
- Palpate the temporal arteries for tenderness, swelling, and hardness. Ask specifically about fever, jaw claudication, scalp tenderness, temporal headaches, and unexpected weight loss. Immediate ESR, CRP, and platelet count when GCA is suspected (see 10.17, ARTERITIC ISCHEMIC OPTIC NEUROPATHY [GIANT CELL ARTERITIS]).
- Temperature and blood pressure.
- Refer the patient to a neurologist, neurosurgeon, otolaryngologist, or internist, as indicated.
NOTE: |
The presence of SVPs classically indicates a normal intracranial pressure. However, about 20% of normal individuals do not have SVPs and thus their absence has little significance. |
Treatment/Follow Up
See individual sections.
Most headaches are not dangerous or ominous; however, they can be symptoms of a life-threatening or vision-threatening problem. Accompanying signs and symptoms that may indicate a life-threatening or vision-threatening headache and some of the specific signs and symptoms of various headaches are listed below.