Investigating severe headache (summary)

This is a basic article for medical students and other non-radiologists

Investigating severe headache (cephalgia is the rarely used medical term for headache ⁵) is a common requirement in both acute and emergency services. It is also common in neurology clinics and GP surgeries. While many of the headaches are benign a large number of patients require radiological investigation ^1,2.

Worldwide, the commonest headaches are tension-type headaches and migraines (90%) ¹. The history of tension headaches and migraines are typical and they are usually not accompanied by physical findings.

Reference article

This is a summary article; we do not have a more in-depth reference article.

Summary

• questions

  • are there any red flags? ³

    • new, different or "worst ever" headache

    • nausea/vomiting

    • altered neurology: paralysis, ataxia, abnormal pupillary response

    • early morning headaches or postural changes

    • confusion or drowsiness

    • new headaches in those over 50 years old

• history

  • are the headaches acute, how long have the headaches been there, how long do they last, are they progressive?

  • where is the pain worst?

  • are they positional (standing/lying/moving)?

  • is there aura (photophobia/phonophobia/nausea)?

  • is there neck stiffness or fever?

• examination

  • cranial nerve examination

  • focal signs may suggest the location of pathology

  • fundoscopy may confirm papilledema which is suggestive of raised intracranial pressure

  • visual field assessment

• investigations

  • CT

    • used in the emergency/acute setting

    • will show hemorrhage/tumor

    • if subarachnoid hemorrhage, CT angiogram can be performed

  • MRI

    • when available, used for assessment of chronic symptoms

    • MR venogram if sinus thrombosis is suspected ⁴

• making the request

  • know what question you are trying to answer

  • are there any red flags?

  • what is the acuity of onset?

  • how urgently does this need to be investigated?​

• common pathology

  • migraine

  • subarachnoid hemorrhage

  • brain tumor

  • venous sinus thrombosis

Teaching playlist

• severe headache playlist