A Synopsis of AFP's Approach to Acute Headache in Adults

A synopsis of 
Approach to Acute Headache in Adults
 BARRY L. HAINER, MD, and ERIC M. MATHESON, MD, Medical University of South Carolina, Charleston, South Carolina
Am Fam Physician. 2013 May 15;87(10):682-687.
http://www.aafp.org/afp/2013/0515/p682.pdf

     When a patient walks in with an acute headache, it must first be determined if the headache is life threatening.  Some illnesses that require prompt evaluation include SAH, hypertensive emergencies, closed angle glaucoma, or a vertebral artery dissection. Some red flags are focal neurological signs (unilateral pronator drift or extensor plantar response), neck stiffness, papilledema, temporal artery tenderness, or having "the worst headache of ones life". Something like this will call for a more extensive evaluation, including neuroimaging, blood tests, or an LP (do the CT first regardless of symptoms). 
     The three most common types of (primary) headaches are tension (40%), migraine (10%) and cluster (1%). Tension headaches are usually bilateral and found more often in women. Infrequent tension headaches occur less than once per month.  Frequent tension headaches can have up to 15 episodes per months. Criteria includes having at least 10 episodes,  headaches lasting 30 minutes to 1 week, nausea and vomiting, and photophobia or phonophobia. The patient must also have at least two of the following: bilateral, pressing or tightening quality, and not aggravated by exertion. 
     Migraine headaches have symptoms that can be remembers by using the "POUND" mnemonic (Pulsatile,  4-72 hours lOng, Unilateral, Nausea and vomiting, Disabling [4/5 for the criteria]). Migraines may or may not have an aura. An aura may be flickering lights, loss of vision, pins and needles, numbness or speech changes.  This usually occurs before a headache and will last less than an hour. 
     Cluster headaches have a unilateral orbital, superolateral, of temporal location. They last from 15-180 minutes and are associated with ipsilateral autonomic symptoms, such as conjunctival injection, lacrimation, congestion. rhinorrhea, sweating, ptosis, miosis, restlessness or aging. They can be sharp, pulsating or pressure-like. Patients may have associated depression, sleep apnea, restless leg syndrome or asthma.  Chronic cluster headaches last for one year at a time, and remission will last for less than one month. Episodic cluster headaches will last 7 days to 1 year, with remissions lasting longer than a month.