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Approach to headache

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Thunderclap onset (peak within a minute): subarachnoid hemorrhage until excluded
    • Fever with neck stiffness or purpura: meningitis, start empirics before imaging
    • New focal deficit, papilledema, or reduced consciousness: mass effect or raised ICP
    • Temporal artery tenderness with visual symptoms over 50: giant cell arteritis, sight is on the clock
    • Headache with pregnancy and hypertension: preeclampsia or venous sinus thrombosis

  2. History that discriminates

    • Onset tempo: thunderclap versus built over hours versus chronic pattern changing
    • The first or the worst headache of their life, or the same old one?
    • Position (worse lying flat suggests pressure; worse standing suggests low pressure), waking from sleep, morning vomiting
    • Precipitants: exertion, coitus, anticoagulants, recent LP, new medication or withdrawal (caffeine, analgesic overuse)
    • Systemic clues: fever, weight loss, jaw claudication, scalp tenderness, immunosuppression

  3. Examination

    • Vitals with temperature and blood pressure
    • Neck stiffness, photophobia; skin for purpura
    • Focal neurology: fields, pupils, pronator drift, gait
    • Fundi for papilledema; temporal arteries in the over-50s

  4. Problem representation

    A 61-year-old on apixaban with the abrupt worst headache of her life and neck stiffness (points at hemorrhage) versus a 24-year-old with recurrent unilateral throbbing headaches, photophobia, and a normal exam (points at migraine).

  5. Differential, by mechanism

    Vascular

    • Subarachnoid hemorrhage
    • Intracerebral bleed
    • Venous sinus thrombosis
    • Giant cell arteritis
    • Dissection

    Infective / inflammatory

    • Meningitis
    • Encephalitis
    • Sinusitis
    • Abscess

    Pressure

    • Mass lesion
    • Idiopathic intracranial hypertension
    • Post-LP low pressure

    Primary

    • Migraine
    • Tension-type
    • Cluster
    • Medication-overuse

  6. Investigations

    • Non-contrast CT head first where any red flag exists
    • LP with opening pressure when CT is clean but suspicion of SAH or meningitis stands (xanthochromia after 12 hours)
    • ESR and CRP the same day when GCA is on the table
    • CT or MR venography for thrombosis weight (pregnancy, thrombophilia, papilledema with normal CT)

  7. Interpretation

    • A normal CT does not close SAH within the first hours nor meningitis at any point; the LP does
    • Red flags trump pattern: a migraineur can still have a bleed, and a changed pattern is itself a flag
    • Opening pressure is data: high with normal imaging points at IIH, low at post-LP or spontaneous hypotension

  8. Next steps

    • Empiric antibiotics plus dexamethasone before any delay when bacterial meningitis is credible
    • Start high-dose steroids on clinical suspicion of GCA; do not wait for the biopsy
    • Primary headache earns treatment AND a safety-net: written advice on the symptoms that change the diagnosis

Connected

FluidThe CSF that answers itFluidThe other CSFApproachWhen the headache brings confusion

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