Acute Headaches, Table 1 International Classification of Table 3 ICHD 2 Diagnostic Criteria for. Headache Disorders 2nd ed ICHD 2 Migraine with Typical Aura. Primary headaches At least two episodes fulfilling the following criteria. Migraine Aura consisting of at least one of the following but no. Tension type motor weakness fully reversible visual symptoms including. positive features e g flickering lights spots or lines and or. negative features i e loss of vision fully reversible sensory. Other e g cold stimulus headache symptoms including positive features i e pins and needles. Secondary headaches and or negative features i e numbness fully reversible. Headache attributed to any of the following head or neck dysphasic speech disturbance. trauma cranial or cervical vascular disorder nonvascular At least two of the following homonymous visual symptoms. intracranial disorder substance use or withdrawal infection and or unilateral symptoms at least one aura symptom. disturbance of homeostasis psychiatric disorder develops gradually over five or more minutes and or. Headache or facial pain attributed to disorder of the cranium different aura symptoms occur in succession over five or. neck eyes ears nose sinuses teeth mouth or other facial more minutes each symptom lasts at least five minutes but. or cranial structures no longer than 60 minutes, A headache that fulfills the criteria for migraine without aura. Adapted with permission from the American Academy of Neurology Table 4 and begins during the aura or follows the aura. Lipton RB Bigal ME Steiner TJ et al Classification of primary head within 60 minutes. aches Neurology 2004 63 3 428 Table 1 First level of The Interna Headache not attributed to another disorder. tional Classification of Headache Disorders 2nd edition http www. neurology org content 63 3 427 abstract, ICHD 2 International Classification of Headache Disorders 2nd ed. Adapted with permission from the American Academy of Neurology. Lipton RB Bigal ME Steiner TJ et al Classification of primary head. aches Neurology 2004 63 3 429 Table 3 ICHD 2 criteria for 1 2 1. Table 2 ICHD 2 Diagnostic Criteria for Typical aura with migraine headache http www neurology org. Episodic Tension Type Headache content 63 3 427 abstract. Infrequent, At least 10 episodes occurring fewer than one day per month quality duration of four to 72 hours unilateral location. on average fewer than 12 days per year and fulfilling the nausea or vomiting and disabling intensity Patients. following criteria who meet at least four of these criteria are most likely to. Headache lasts 30 minutes to seven days,have a migraine 14. Headache has at least two of the following features bilateral. location pressing or tightening nonpulsating quality mild. One study of 1 500 adults with migraine headache, or moderate intensity not aggravated by routine physical found that the presence of nausea alone or the presence. activity such as walking or climbing stairs of two of three features from either of these symptom. Both of the following no nausea or vomiting anorexia may triads i e nausea photophobia and pulsating qual. occur either photophobia or phonophobia ity or nausea photophobia and worsening of headache. Headache is not attributed to another disorder with physical activity had positive likelihood ratios for. migraine of 4 8 or greater and negative likelihood ratios. At least 10 episodes occurring on more than one but fewer than. of less than 0 23 15, 15 days per month for at least three months and fulfilling all of. the criteria for infrequent episodic tension type headache Aura may be present in some cases of migraine. Aura consists of visual sensory or speech symptoms. ICHD 2 International Classification of Headache Disorders 2nd ed that appear gradually last no longer than 60 minutes. Adapted with permission from the American Academy of Neurol and are completely reversible Table 3 lists criteria for. ogy Lipton RB Bigal ME Steiner TJ et al Classification of primary migraine with aura5 Table 4 lists criteria for migraine. headaches Neurology 2004 63 3 431 Table 4 ICHD 2 criteria for. episodic tension type headache TTH http www neurology org without aura 5. content 63 3 427 abstract,CLUSTER HEADACHES, Cluster headaches are relatively rare and are charac. MIGRAINE HEADACHES terized by brief 15 to 180 minutes episodes of severe. Useful clinical criteria from the history and physical head pain with associated autonomic symptoms1. examination for distinguishing migraine from tension Table 54 Although cluster headaches are less com. type headache include nausea photophobia sensitiv mon than migraines and tension type headaches an. ity to light and phonophobia sensitivity to sound estimated 500 000 Americans experience them at least. Physical activity often exacerbates migraine headache once in a lifetime 16 The age of onset of cluster headaches. Combined findings useful for distinguishing migraine varies with 70 percent of patients reporting onset before. can be summarized by the POUND mnemonic pulsatile 30 years of age 17. May 15 2013 Volume 87 Number 10 www aafp org afp American Family Physician 683. Acute Headaches, Table 4 ICHD 2 Diagnostic Criteria for Table 6 Criteria for Low Risk Headaches. Migraine Without Aura,Age younger than 30 years, At least five episodes fulfilling the following criteria Features typical of primary headaches Tables 1 through 5. Headache episodes lasting four to 72 hours untreated or History of similar headache. unsuccessfully treated No abnormal neurologic findings. Headache has at least two of the following characteristics No concerning change in usual headache pattern. unilateral location pulsating quality moderate or severe. No high risk comorbid conditions e g human, pain intensity aggravated by or causes avoidance of. immunodeficiency virus infection, routine physical activity such as walking or climbing stairs. No new concerning historical or physical examination findings. During the headache the patient experiences at least one of. the following nausea or vomiting and photophobia and. phonophobia,Information from reference 6,Headache is not attributed to another disorder. ICHD 2 International Classification of Headache Disorders 2nd ed. pain There tend to be several up to eight episodes in. Adapted with permission from the American Academy of Neurology. Lipton RB Bigal ME Steiner TJ et al Classification of primary head the same day with each episode lasting between 15 and. aches Neurology 2004 63 3 428 Table 2 ICHD 2 diagnostic crite 180 minutes 4 In the episodic form 80 to 90 percent of. ria for 1 1 Migraine without aura http www neurology org content. cases episodes occur daily for a number of weeks fol. 63 3 427 abstract, lowed by a period of remission 4 On average a period of. cluster headaches lasts six to 12 weeks with remission. lasting up to 12 months 4 In the chronic form 10 to. Table 5 ICHD 2 Diagnostic Criteria for 20 percent of cases episodes occur without significant. Cluster Headache periods of remission 4, The long delay in diagnosis reported by patients who. At least five episodes fulfilling the following criteria have cluster headaches is important Only 25 percent of. Severe or very severe unilateral orbital supraorbital or patients with cluster headaches are diagnosed correctly. temporal pain lasting 15 to 180 minutes if untreated within one year of symptom onset and more than 40 per. Headache is accompanied by at least one of the following cent report a delay in diagnosis of five years or longer 16. ipsilateral autonomic symptoms conjunctival injection or The most common incorrect diagnoses reported in one. lacrimation nasal congestion or rhinorrhea eyelid edema. forehead and facial sweating miosis or ptosis restlessness. study were migraine 34 percent sinusitis 21 percent. or agitation and allergies 6 percent 15 Family history appears to. Headache episodes occur from one every other day to eight have a role in some cases A number of comorbidities are. per day associated with cluster headaches including depression. Not attributable to another disorder 24 percent sleep apnea 14 percent restless legs syn. Episodic cluster headache drome 11 percent and asthma 9 percent 15 Depression. Fulfills all of the above criteria is an important diagnosis because many individuals who. At least two cluster periods lasting seven to 365 days and have cluster headaches report suicidal thoughts and 2 per. separated by pain free remissions of more than one month. cent of patients in one study had attempted suicide 16 18 19. Chronic cluster headache,Fulfills all of the above criteria. Dangerous Headaches, Episodes recur for more than one year without remission periods. or with remission periods lasting less than one month Distinguishing dangerous headaches from benign or. low risk headaches is a significant challenge because the. ICHD 2 International Classification of Headache Disorders 2nd ed symptoms can overlap Recommendations for differenti. Information from reference 4 ating dangerous from benign headaches are provided in. Table 7 5 20 24 The characteristics of dangerous headaches. and associated red flag symptoms are based on observa. Patients with cluster headache most commonly tional study and consensus reports Therefore they are. describe the pain as sharp but some report that it can also not absolutely accurate in identifying serious underlying. be pulsating and pressure like Although pain can occur causes in patients who have headache. on both sides of the head most patients report unilateral Patients with characteristics of secondary headache. pain Pain most commonly occurs in the retro orbital should be evaluated to determine whether the headache. area followed by the temporal region upper teeth jaw is dangerous Computed tomography of the head is the. cheek lower teeth and neck 17 Ipsilateral autonomic most widely used imaging study for acute head trauma. symptoms such as eyelid edema nasal congestion lac because of its availability speed and accuracy How. rimation or forehead sweating usually accompany the ever magnetic resonance imaging of the brain is more. 684 American Family Physician www aafp org afp Volume 87 Number 10 May 15 2013. Acute Headaches, Table 7 Red Flag Signs and Symptoms in the Evaluation of Acute Headache. Danger sign or symptom Possible diagnoses Tests, First or worst headache of the patient s life Central nervous system infection intracranial Neuroimaging. hemorrhage, Focal neurologic signs not typical aura Arteriovenous malformation collagen vascular Blood tests neuroimaging. disease intracranial mass lesion, Headache triggered by cough or exertion Mass lesion subarachnoid hemorrhage Lumbar puncture neuroimaging. or while engaged in sexual intercourse, Headache with change in personality Central nervous system infection intracerebral Blood tests lumbar puncture. mental status level of consciousness bleed mass lesion neuroimaging. Neck stiffness or meningismus Meningitis Lumbar puncture. New onset of severe headache in Cortical vein cranial sinus thrombosis carotid Neuroimaging. pregnancy or postpartum artery dissection pituitary apoplexy. Older than 50 years Mass lesion temporal arteritis Erythrocyte sedimentation rate. neuroimaging, Papilledema Encephalitis mass lesion meningitis pseudotumor Lumbar puncture neuroimaging. Rapid onset with strenuous exercise Carotid artery dissection intracranial bleed Neuroimaging. Sudden onset maximal intensity occurs Bleeding into a mass or arteriovenous Lumbar puncture neuroimaging. within seconds to minutes thunderclap malformation mass lesion especially posterior. headache fossa subarachnoid hemorrhage, Systemic illness with headache fever rash Arteritis collagen vascular disease encephalitis Blood tests lumbar puncture. meningitis neuroimaging skin biopsy, Tenderness over temporal artery Polymyalgia rheumatica temporal arteritis Erythrocyte sedimentation rate. temporal artery biopsy, Worsening pattern History of medication overuse mass lesion Neuroimaging. subdural hematoma,New headache type in a patient with. Cancer Metastasis Lumbar puncture neuroimaging, Human immunodeficiency virus infection Opportunistic infection tumor Lumbar puncture neuroimaging. Lyme disease Meningoencephalitis Lumbar puncture neuroimaging. Information from references 5 and 20 through 24, sensitive for detecting subdural hematoma and is with headache may suggest a brain abscess meningitis. therefore particularly important in identifying smaller or malignancy of the central nervous system CNS 21 26. lesions 20 The presence of a coexisting infection in the lungs. An algorithm for diagnosing headaches is available sinuses or orbital areas may precede and cause a CNS. from the Institute for Clinical Systems Improvement at infection. https www icsi org asset qwrznq Headache pdf 3 A patient who reports the worst headache of his or. her life especially if the patient is older than 50 years or. HISTORY AND PHYSICAL EXAMINATION who has a headache that occurs with exertion includ. History Thunderclap headache which is characterized by ing sexual intercourse could be experiencing intracra. sudden onset headache pain with peak intensity occur nial hemorrhage or carotid artery dissection 26 Prompt. ring within several minutes requires prompt evaluation investigation is required for any headaches associated. Subarachnoid hemorrhage hypertensive emergencies with neurologic findings including changes in mental. vertebral artery dissections and acute angle closure status seizures and visual disturbances Additional red. glaucoma can also present this way 25 flag symptoms and signs are listed in Table 7 5 20 24. Use of illicit drugs including cocaine and metham Physical Examination Neurologic abnormalities. phetamine can increase the risk of intracranial bleeding require evaluation and are particularly concerning in. or stroke Prescription or over the counter medications association with acute headache Abnormalities are one. such as aspirin other nonsteroidal anti inflammatory of the best predictors of CNS pathology 6 14 27 A focal. drugs anticoagulants and glucocorticoids increase the neurologic deficit should not be attributed to migraine. risk of intracranial bleeding headache unless a similar pattern has occurred with a. A history of human immunodeficiency virus infec previous migraine By definition aura associated with. tion or other immunosuppressive conditions in patients migraine lasts 60 minutes or less Therefore headache. May 15 2013 Volume 87 Number 10 www aafp org afp American Family Physician 685. Acute Headaches,SORT KEY RECOMMENDATIONS FOR PRACTICE. Clinical recommendation rating References, A diagnosis of migraine is highly likely with presence of headache with nausea or if the patient reports C 15. experiencing two of three features from either of these symptom triads nausea photophobia or. pulsating pain or nausea photophobia or a headache that worsens with exertion. Head computed tomography should be performed before lumbar puncture in all patients with C 23. suspected subarachnoid hemorrhage regardless of findings on neurologic examination. A patient with sudden onset of severe headache e g patient reporting the worst headache of his or C 28. her life or maximal from initiation or thunderclap headache should be evaluated with computed. tomography of the head without contrast media, Immunocompromised patients with severe headache should be evaluated with magnetic resonance C 28. imaging of the head with and without contrast media. A consistent good quality patient oriented evidence B inconsistent or limited quality patient oriented evidence C consensus disease. oriented evidence usual practice expert opinion or case series For information about the SORT evidence rating system go to http www aafp. org afpsort xml, with aura like symptoms should not be assumed to be subarachnoid hemorrhage it is important to perform. benign or a primary headache when aura like symptoms lumbar puncture to check for blood or xanthochromia. are present for more than 60 minutes Computed tomography of the head should be performed. Abnormal findings on examination can be pro before lumbar puncture even if the results of neurologic. nounced such as meningismus or unilateral vision loss examination are normal because there is a risk of cen. or subtle such as extensor plantar response or unilat tral herniation of the brain even in the absence of physi. eral pronator drift Obtundation or confusion suggests cal examination findings of subarachnoid hemorrhage. a dangerous headache because these signs do not occur In one supporting study 5 percent of patients presenting. with benign or primary headache to an emergency department with suspected subarach. Patients with headache and fever papilledema or noid hemorrhage and a normal neurologic examination. severe hypertension systolic pressure greater than 180 had early intracranial herniation or midline shift 29. mm Hg or diastolic pressure greater than,120 mm Hg require evaluation for CNS. infection and increased intracranial pres, Table 8 American College of Radiology Recommendations. sure Patients also should be evaluated to for Neuroimaging in Patients with Headache. determine if their blood pressure should be, lowered to safer levels to avoid intracranial Clinical features Recommended imaging modality. hemorrhage from malignant hypertension, Contusions and facial or scalp lacerations Headache in immunocompromised MRI of the head with and without. patients contrast media,increase the likelihood of associated intra. Headache in patients older than MRI of the head with and without. cranial hemorrhage Table 7 5 20 24,60 years with suspected temporal contrast media. DIAGNOSTIC TESTING, Headache with suspected meningitis CT or MRI of the head without contrast. Neuroimaging Neuroimaging is indicated for media, all patients who present with signs or symp Severe headache in pregnancy CT or MRI of the head without contrast. toms of dangerous headache because they media, Severe unilateral headache caused MRI of the head with and without. are at increased risk of intracranial pathol, by possible dissection of the contrast media MRA of the head and. ogy Although considerable debate exists carotid or arterial arteries neck or CTA of the head and neck. about the optimal way to perform neuro Sudden onset or severe headache CT of the head without contrast. imaging for acute headaches the American worst headache of the patient s life media CTA of the head with contrast. College of Radiology has made a few specific media MRA of the head with or. without contrast media or MRI of, recommendations Table 8 28 the head without contrast media. Lumbar Puncture Lumbar puncture is, useful for identifying infection the presence CT computed tomography CTA computed tomographic angiography MRA. of red blood cells which suggests bleeding magnetic resonance angiography MRI magnetic resonance imaging. and abnormal cells associated with some Information from reference 28. CNS malignancies In adults with suspected, 686 American Family Physician www aafp org afp Volume 87 Number 10 May 15 2013. Acute Headaches, Response to Pain Relief The American College of 11 Fern ndez de Las Pe as C Cuadrado ML Arendt Nielsen L Ge HY. Pareja JA Increased pericranial tenderness decreased pressure pain. Emergency Physicians has determined that response to threshold and headache clinical parameters in chronic tension type. pain relief therapy should not be used as the sole diag headache patients Clin J Pain 2007 23 4 346 352. nostic indicator of the underlying etiology of an acute 12 Buchgreitz L Lyngberg AC Bendtsen L Jensen R Frequency of headache. is related to sensitization a population study Pain 2006 123 1 2 19 27. headache 13 No prospective randomized controlled trials. 13 Edlow JA Panagos PD Godwin SA Thomas TL Decker WW Ameri. evidence from meta analyses randomized controlled can College of Emergency Physicians Clinical policy critical issues in. trials or well designed cohort studies support or refute the evaluation and management of adult patients presenting to the. the practice of using response to pain relief therapy in emergency department with acute headache Ann Emerg Med 2008. 52 4 407 436, nontraumatic headaches as an indicator of potential. 14 Detsky ME McDonald DR Baerlocher MO Tomlinson GA McCrory DC. underlying pathology Booth CM Does this patient with headache have a migraine or need. neuroimaging JAMA 2006 296 10 1274 1283, Data Sources We performed a PubMed search for headache topics and. reviewed recent relevant publications in the Cochrane database Essen 15 Martin VT Penzien DB Houle TT Andrew ME Lofland KR The pre. tial Evidence Plus and the National Guideline Clearinghouse The search dictive value of abbreviated migraine diagnostic criteria Headache. 2005 45 9 1102 1112, included expert consensus statements clinical reviews and clinical trials. Search terms included headache acute headache and classification of 16 Torelli P Manzoni GC Pain and behaviour in cluster headache A prospec. headache Search date December 2011 tive study and review of the literature Funct Neurol 2003 18 4 205 210. 17 Rozen TD Fishman RS Cluster headache in the United States of Amer. ica demographics clinical characteristics triggers suicidality and per. The Authors sonal burden Headache 2012 52 1 99 113. 18 J rgens TP Gaul C Lindwurm A et al Impairment in episodic and. BARRY L HAINER MD is a professor in the Department of Family Medi chronic cluster headache published correction appears in Cephalalgia. cine at the Medical University of South Carolina in Charleston 2011 31 6 766 Cephalalgia 2011 31 6 671 82. ERIC M MATHESON MD is an assistant professor in the Department of 19 Bahra A May A Goadsby PJ Cluster headache a prospective clinical. Family Medicine at the Medical University of South Carolina study with diagnostic implications Neurology 2002 58 3 354 361. 20 Edmeads J Emergency management of headache Headache 1988. Address correspondence to Barry L Hainer MD Medical University of 28 10 675 679. South Carolina MSC 192 Charleston SC 29425 e mail hainerbl musc 21 Clinch CR Evaluation of acute headaches in adults Am Fam Physician. edu Reprints are not available from the authors 2001 63 4 685 692. Author disclosure No relevant financial affiliations 22 Silberstein SD Lipton RB Dalessio DJ Overview diagnosis and clas. sification of headache In Silberstein SD Lipton RB Dalessio DJ eds. Wolff s Headache and Other Head Pain 7th ed New York NY Oxford. REFERENCES University Press 2001 6 26, 1 Stovner LJ Hagen K Jensen R et al The global burden of headache 23 Ramirez Lassepas M Espinosa CE Cicero JJ Johnston KL Cipolle RJ. a documentation of headache prevalence and disability worldwide Barber DL Predictors of intracranial pathologic findings in patients. Cephalalgia 2007 27 3 193 210 who seek emergency care because of headache Arch Neurol 1997. 54 12 1506 1509, 2 Leroux E Ducros A Cluster headache Orphanet J Rare Dis 2008 3 20. 24 Ramchandren S Cross BJ Liebeskind DS Emergent headaches during. 3 Beithon J Gallenberg M Johnson K et al Diagnosis and treatment of pregnancy correlation between neurologic examination and neuroim. headache 11th ed Institute for Clinical Systems Improvement January aging AJNR Am J Neuroradiol 2007 28 6 1085 1087. 2013 https www icsi org asset qwrznq Headache pdf Accessed. 25 Pascual J Gonz lez Mandly A Mart n R Oterino A Headaches pre. March 17 2013, cipitated by cough prolonged exercise or sexual activity a prospective. 4 Headache Classification Subcommittee of the International Headache etiological and clinical study J Headache Pain 2008 9 5 259 266. Society The international classification of headache disorders 2nd edi. 26 Rothman RE Keyl PM McArthur JC Beauchamp NJ Jr Danyluk T Kelen. tion Cephalalgia 2004 24 suppl 1 9 160, GD A decision guideline for emergency department utilization of non. 5 Lipton RB Bigal ME Steiner TJ Silberstein SD Olesen J Classification of contrast head computed tomography in HIV infected patients Acad. primary headaches Neurology 2004 63 3 427 435 Emerg Med 1999 6 10 1010 1019. 6 American College of Emergency Physicians Clinical policy critical 27 Locker TE Thompson C Rylance J Mason SM The utility of clinical fea. issues in the evaluation and management of patients presenting to tures in patients presenting with nontraumatic headache an investiga. the emergency department with acute headache Ann Emerg Med tion of adult patients attending an emergency department Headache. 2002 39 1 108 122 2006 46 6 954 961, 7 Gentry LR Godersky JC Thompson B Dunn VD Prospective compara 28 Strain JD Strife JL Kushner DC et al Headache American College of. tive study of intermediate field MR and CT in the evaluation of closed Radiology ACR appropriateness criteria Radiology 2000 215 suppl. head trauma AJR Am J Roentgenol 1988 150 3 673 682 855 860. 8 Schwartz BS Stewart WF Simon D Lipton RB Epidemiology of tension 29 Baraff LJ Byyny RL Probst MA Salamon N Linetsky M Mower WR. type headache JAMA 1998 279 5 381 383 Prevalence of herniation and intracranial shift on cranial tomography. 9 Ashina M Neurobiology of chronic tension type headache Cephalal in patients with subarachnoid hemorrhage and a normal neurologic. gia 2004 24 3 161 172 examination Acad Emerg Med 2010 17 4 423 428. 10 Bendtsen L Fern ndez de la Pe as C The role of muscles in tension. type headache Curr Pain Headache Rep 2011 15 6 451 458. May 15 2013 Volume 87 Number 10 www aafp org afp American Family Physician 687.
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