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.

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: cranial nerve palsies, hemibody weakness or bulbar 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).

Life or Vision Threatening

• GCA: Age ≥55 years. May have high ESR, CRP, and platelet count. See 10.17, Arteritic Ischemic Optic Neuropathy (Giant Cell Arteritis).

• Acute angle-closure glaucoma: Decreased vision, painful eye, fixed mid-dilated pupil, and high intraocular pressure. See 9.4, Acute Angle Closure Attack.

• Ocular ischemic syndrome: Periorbital eye pain. See 11.11, Ocular Ischemic Syndrome/Carotid Occlusive Disease. 

• Malignant hypertension: Marked increase of blood pressure, often accompanied by retinal cotton–wool spots, hemorrhages, and, when severe, optic nerve swelling. See 11.10, Hypertensive Retinopathy.

• Increased intracranial pressure: May have papilledema and/or a sixth cranial nerve palsy. Headaches usually worse in the morning and with Valsalva. See 10.15, Papilledema.

• Infectious CNS disorder (meningitis or brain abscess): Fever, stiff neck, mental status changes, photophobia, and neurologic signs.

• Structural abnormality of the brain (e.g., tumor, aneurysm, AVM): Mental status change, signs of increased intracranial pressure, or neurologic signs during, and often after, the headache episode.

• Subarachnoid hemorrhage: Extremely severe headache (classically described as a thunderclap headache), stiff neck, mental status change; rarely, subhyaloid hemorrhages seen on fundus examination, usually from a ruptured aneurysm.

• Epidural or subdural hematoma: Follows head trauma; altered level of consciousness; may produce anisocoria or cranial neuropathy.

Others

• Migraine (see 10.27, Migraine).

• Cluster headache (see 10.28, Cluster Headache).

• Tension headache.

• Varicella zoster virus: Headache or pain may precede the herpetic vesicles (see 4.17, Herpes Zoster Ophthalmicus/Varicella Zoster Virus).

• Sinus disease.

  NOTE A “sinus” headache may be a serious headache in diabetic patients and immunocompromised hosts given the possibility of zygomycosis infection (e.g., mucormycosis).

• Tolosa–Hunt syndrome.

• Cervical spine disease.

• Temporomandibular joint syndrome.

• Dental disease.

• Trigeminal neuralgia (tic douloureux).

• Anterior uveitis: See 12.1, Anterior Uveitis (Iritis/Iridocyclitis).

• Status post LP.

• Paget disease.

• Depression/psychogenic.

• Convergence insufficiency: See 13.5, Convergence Insufficiency.

• Accommodative spasm: See 13.6, Accommodative Spasm.

1. 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?

2. Complete ocular examination, including pupillary, motility, and visual field evaluation; intraocular pressure measurement, optic disc and SVP assessment, and a dilated retinal examination. Manifest and cycloplegic refractions may be helpful.

   NOTE The presence of SVPs classically indicates a normal intracranial pressure. About 20% of normal individuals do not have SVPs and thus their absence has little significance.

3. Neurologic examination (check neck flexibility and other meningeal signs).

4. 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]).

5. Temperature and blood pressure.

6. Refer the patient to a neurologist, neurosurgeon, otolaryngologist, or internist, as indicated.

Treatment/Follow-Up

See individual sections.