The patient complains of a dull, steady pain, described as an
ache, pressure, throb, or constricting band, located anywhere from eyes to
occiput, perhaps including the neck or shoulders. Most commonly, the headache
develops near the end of the day, or after some particular stress. The pain
may improve with rest, aspirin, acetaminophen, or other medications. The
physical exam will be unremarkable except for cranial or posterior muscle
spasm or tenderness.
What to do:
Perform a complete general history (including environmental factors and
foods which precede the headaches) and physical examination (including a
If the patient complains of sudden onset of the "worst headache of my
life," accompanied by any change in mental status, weakness, vomiting,
seizures, stiff neck, or persistent neurologic abnormalities, suspect a
cerebrovascular cause, especially a subarachnoid hemorrhage, intracranial
hemorrhage, or arteriovenous malformation. The best initial diagnostic test
for these is computed tomography, but when CT is not available and the patient
does not have papilledema or other signs of increased intracranial pressure,
rule out these problems with a lumbar puncture.
If the headache is accompanied by fever and stiff neck, or change in mental
status, you need to rule out bacterial meningitis as soon as possible, again
with lumbar puncture.
If the headache was preceded by ophthalmic or neurologic symptoms, now
resolving, suggestive of a migraine headache, you may want to try sumatriptan or ergotamine therapy. If vasospastic symptoms persist into the headache phase, the etiology may still be a migraine, but it becomes more
important to rule out other cerebrovascular causes.
If the headache follows prolonged reading, driving, or television watching,
and decreased visual acuity is improved by viewing through a pinhole, the
headache may be due to a defect in optical refraction, curable with new
If the temples are tender, check for visual defects and myalgias that
accompany temporal arteritis.
If there is a history of recent dental work or grinding of teeth,
tenderness anterior to the tragus, or crepitus on motion of the jaw, suspect
arthritis of the temperomandibular joint .
If there is fever, tenderness to percussion over the frontal or maxillary
sinuses, purulent drainage visible in the nose, or facial pain exacerbated by
lowering the head, consider sinusitis.
If pain radiates to the ear, be sure to inspect and palpate the teeth,
which are a common site of referred pain.
Finally, after checking for all these other causes of headache, palpate the
temporalis, occipitalis, and other muscles of the calvarium and neck, looking
for areas of tenderness and spasm which usually accompany muscle tension
headaches. Keep an eye out for especially tender trigger points which may resolve with gentle pressure or massage.
Prescribe anti-inflammatory analgesics (ibuprofen, naproxen), recommend
rest, and have the patient try cool compresses and massage of any trigger
Explain the etiology and treatment of muscle spasm of the head and neck.
Volunteer the information that you see no evidence of other serious disease
(if this is true); especially that a brain tumor is unlikely. (Often this is a
fear which is never voiced.)
Arrange for followup. Instruct the patient to return to the ED or contact
his own physician if symptoms change or worsen.
What not to do:
Do not discharge without followup instructions. Many serious illnesses
begin with a minor cephalgia, and patients may postpone urgent; care in the
belief that they have been definitively diagnosed on the first visit.
Do not miss subarachnoid hemorrhage and meningitis. (If you are not
obtaining a majority of negative CTs and LPs, you may not be looking hard
Headaches are common and most are benign, but any headache brought
to medical attention deserves a thorough evaluation. Screening tests are of
little value--a laborious history and physical examination are required. Other
causes of headache include carbon monoxide exposure from wood heaters, fevers
and viral myalgias, caffeine withdrawal, hypertension, glaucoma, tic
douloureux (trigeminal neuralgia) and intolerance of foods containing
nitrite, tyramine, xanthine. Tension headache is not a wastebasket diagnosis
of exclusion but a specific diagnosis, confirmed by palpating tenderness in
craniocervical muscles. ("Tension" refers to muscle spasm more than life
stress.) Tension headache is often dignified with the diagnosis of " migraine"
without any evidence of a vascular etiology, and is often treated with minor
tranquilizers, which may or may not help. Focal tenderness over the greater
occipital nerves (C2, 3) can be associated with an occipital neuralgia or
occipital headache, and be secondary to cervical radiculopathy from cervical
spondylosis. These tend to occur in older patients and should not be confused
with tension headache. Remember to probe for the patient's hidden agenda.
"Headache" may often be the justification for seeing a physician when some
other physical, emotional, or social concern is actually the patient's major