Investigating severe headache (summary)

Last revised by Henry Knipe on 23 Sep 2023
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.

  • 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

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Cases and figures

  • Case 1: subarachnoid hemorrhage
    Drag here to reorder.
  • Case 2: transverse sinus thrombosis
    Drag here to reorder.
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