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Headache - assessment - Management
What serious secondary causes for headache must I exclude?

  • Suspect a serious cause if a headache:
    • Follows trauma to the head and the headache is progressive, and especially if it is associated with impaired consciousness and/or a focal neurological deficit. If this occurs, suspect an epidural or subdural haematoma.
    • Is sudden, with a rapid time to peak headache intensity (that is, from a few seconds to 5 minutes). If this occurs, suspect a subarachnoid haemorrhage.
    • Develops simultaneously with a sudden onset of neurological impairment of speech, sensation, power, or consciousness, especially if the impairment lasts longer than 1 hour. If this occurs, suspect a transient ischaemic attack or stroke (including subarachnoid haemorrhage).
    • Is associated with fever and impaired consciousness, neck stiffness, or photophobia. If this occurs, suspect an intracranial infection (such as meningitis or encephalitis).
    • Is associated with tenderness over the temporal artery in a person older than 50 years of age. If this occurs, suspect giant cell arteritis.
    • Is associated with features indicating a high risk of a space occupying lesion, including people with:
      • A new headache accompanied by features suggestive of raised intracranial pressure, including papilloedema, vomiting, posture-related headache, or headache waking them from sleep (unless it is clearly cluster headache).
      • A new headache accompanied by focal neurological symptoms, or non-focal neurological symptoms such as blackout, change in personality or memory.
      • An unexplained headache that becomes progressively severe.
      • An unexplained headache in anyone previously diagnosed with cancer.
      • A new-onset of epileptic seizures.
    • Is associated with features indicating a moderate risk of a space occupying lesion, including people with:
      • A new headache, when a diagnostic headache pattern has not emerged after 8 weeks.
      • A new headache, in a person older than 50 years of age.
    • Is associated with severe unilateral eye pain, red eye, fixed and dilated pupil, hazy cornea, or diminished vision. If this occurs, suspect acute glaucoma.
    • Is associated with nausea and impaired concentration in a person exposed to a potential carbon monoxide source, including smoke, engine exhausts, or gases from gas or solid fuel appliances retained in an enclosed space. Severe poisoning can cause impaired consciousness, chest pain, and a wide range of neurological deficits.
  • If symptoms of a serious cause of headache are excluded assess for medication-overuse and other secondary causes of headache.

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