How to evaluate HEADACHE 🤔

 

🧠 How to Evaluate HEADACHE

Headache is one of the most common reasons for medical visits—but also one of the easiest to misjudge. A systematic approach helps you immediately distinguish benign headaches from life-threatening ones.

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1️⃣ Start With the Most Important Step: Is it Dangerous?

Always rule out secondary causes first.

🚨 Red Flags — SNOOP10

If ANY of these are present, think secondary headache:

S – Systemic symptoms (fever, weight loss) or systemic disease (HIV, cancer)

N – Neurological symptoms/signs (focal deficits, altered sensorium)

O – Onset sudden (thunderclap, reaches peak in < 1 min)

O – Older age (>50 years)

P – Pattern change or first/worst headache

Plus “10 extras”

Precipitated by Valsalva/exertion/cough

Papilledema

Positional headache

Pregnancy/postpartum

Painful eye + autonomic symptoms

Post-trauma

Progressive worsening

Paroxysmal with exertion/sex

Poor immunity (steroids, chemo)

Pharmacologic causes (anticoagulants → bleed)

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2️⃣ Take a Structured History – The 7 Key Questions 📝

1. Onset

Sudden (→ SAH, CVT, dissection)

Gradual (→ migraine, tension)

2. Location

Hemicranial → Migraine

Orbital → Cluster / angle-closure glaucoma

Occipital → Cervicogenic / hypertension / posterior circulation

3. Duration & frequency

Seconds → Neuralgia

30 min–3 hrs → Cluster

4–72 hrs → Migraine

Daily/continuous → NDPH, MOH

4. Character

Pulsatile → Migraine

Pressing/tight → Tension-type

Stabbing/shock-like → Trigeminal neuralgia

5. Associated symptoms

Nausea/vomiting, photophobia → Migraine

Tearing, rhinorrhea → Trigeminal autonomic cephalalgias

Fever/rigidity → Meningitis

Vision loss/Jaw claudication → GCA

6. Triggers

Stress, sleep deprivation, menses → Migraine

Alcohol → Cluster

Cough/exertion → Structural lesion

7. Medication use

Frequent NSAIDs, triptans → Medication-overuse headache (MOH)

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3️⃣ Focused Examination

General exam

Fever (meningitis)

BP (HTN crisis)

Scalp tenderness (GCA)

Neurological exam

Cranial nerves

Motor/sensory

Gait, reflexes

Meningeal signs

Fundoscopy

Papilledema

Hemorrhages

Optic pallor

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4️⃣ When to Order Investigations?

Neuroimaging

Non-contrast CT head—first-line for:

Thunderclap headache

Trauma

Focal neuro deficits

Suspected raised ICP

MRI brain

Persistent headaches with normal CT

Suspicion of tumor, CVT, posterior fossa lesions

Chronic progressive headaches

MRV/CTV

Suspected cerebral venous thrombosis

(postpartum, OCP use, dehydration)

Lumbar puncture

Do after normal CT if:

Suspicion of SAH but CT negative

Meningitis/encephalitis

Idiopathic intracranial hypertension (opening pressure)

Blood tests

ESR/CRP → Suspect GCA (>50 years)

CBC → Infection, anemia

Pregnancy test → If imaging needed

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5️⃣ Differentiate Common Primary Headaches

🎯 Migraine

Unilateral throbbing

Nausea/vomiting

Photophobia/phonophobia

± Aura

Worse with routine activity

🎯 Tension-Type

Bilateral, band-like pressure

Mild–moderate

No nausea/vomiting

Stress-related

🎯 Cluster Headache

Severe, unilateral orbital pain

Tearing, rhinorrhea, red eye

Occurs in clusters at same time daily

“Suicide headache”

🎯 Medication-Overuse Headache

Daily near-constant headache

Using analgesics >10–15 days/month

Improves after withdrawal

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6️⃣ Life-Threatening Causes Not to Miss 🚑

Subarachnoid hemorrhage

Meningitis/Encephalitis

Cerebral venous thrombosis

Temporal arteritis

Acute angle-closure glaucoma

Hypertensive emergency

Intracranial tumor/mass effect

Carbon monoxide poisoning

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7️⃣ Putting It All Together: The FAST Algorithm

F – Flag?

Any red flags → URGENT imaging/LP.

A – Ask structured questions

Onset, location, duration, character, associated symptoms, triggers.

S – Scan when needed

CT → emergencies

MRI → subacute/chronic cases

T – Treat appropriately

Primary headaches → symptomatic + preventive therapy

Secondary → treat underlying cause

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✅ Summary Table (Ultra High-Yield)

Step What You Do

1. Rule out danger SNOOP10 red flags

2. History Onset, location, character, frequency, triggers, meds

3. Examination Neuro + fundus + systemic

4. Investigations CT/MRI/LP based on suspicion

5. Diagnose Migraine, TTH, cluster, MOH, or secondary cause

6. Treat Targeted therapy or emergency management