Diagnosis is key. Our main goal is to rule out life-threatening or other critical conditions. If we have reason to suspect any diseases in the first column below, we might send them to an ER. Here we present the clinician’s condensed thought process when face-to-face with a patient; see also Acute Headache — Full Text for a more in-depth explanation, or see links to specific diseases.
We always want to be sure they don’t have other symptoms of Covid-19. But we can’t just send them off for a test if they may have diseases in the first column below. Every site has its own way of addressing this. The rest of this discussion assumes we’ve ruled it out. See also Covid-19.
Causes of Acute Headache
|zz zzDo Not Miss (rare)||zzzzMore Common Conditions|
|** Subarachnoid Hemorrhage|
** Increased Intracranial Pressure (in brain)
** Meningitis (and other brain infections)
** AIDS-Related Illness
** Carbon Monoxide Poisoning
** Temporal Arteritis
** Epidural Hematoma
** Anemia (if acute or severe)
** Hypertension (severe)
** Acute Closed-Angle Glaucoma
** Depressed and Suicidal
|** Allergic Rhinitis (hay fever)|
** Influenza (& other illnesses with fever)
** Neck Sprain or Strain
** Medications / Drugs / Toxins / Irritants
** Head Trauma (minor)
** “Normal” Headache
** Stress, Anxiety, Depression
First Episode of “Recurrent Headache“
Beginning of “Chronic Headache”
We rule out “Do Not Miss” systematically. If we suspect any of those conditions, we proceed with diagnosis as explained in the link, or in our Full Text discussion.
If vital signs are normal, we can easily exclude:
- Age <50 means NO Temporal Arteritis (if older, & new headache, we order a “Sed Rate“);
- Blood pressure isn’t sky-high [NO Hypertensive Emergency];
- No fever [NOT Meningitis, brain infection or other serious infection].
As we enter the room & greet the patient, we see they look comfortable [NOT Acute Glaucoma].
So we begin our history, focusing initially on time frame. As we establish this is a new “Acute Headache,” not chronic and not recurrent (never had it before), we ascertain that this is not the “worst headache ever,” or if it is, it didn’t reach maximum intensity immediately [NOT a Subarachnoid Hemorrhage].
In the course of our visit, we’ll ask a few target questions, & make some key observations, to rule out other life-threatening conditions in the “Do Not Miss” column:
- No trauma within the last 1-2 days [NOT an Epidural Hematoma];
- The setting does NOT suggest Carbon Monoxide Poisoning (breathe easier);
- There’s no shortness of breath with walking [will NOT be acute or severe Anemia];
- No risk-factors for HIV, has tested HIV negative in past few years [NOT likely AIDS-Related];
- We observe that history is straight-forward and makes sense, with NO reason to suspect possible Suicidality.
In the backs of our minds, we’ll wonder if this is one of the very few “headaches” which might warrant a Head CT Scan to rule out Tumor other cause of Increased Pressure on the Brain:
- Occur daily and progress in severity;
- Associated with daily nausea / vomiting;
- Worsen with straining or bending forward (as a prominent feature, and in association with one of the above, or with age >50);
- Elderly, or taking anticoagulants, especially if they’d had even the most minor of head trauma within the past few months.
We also perform a Neurological Exam. But if they look well & act appropriately, it’ll probably be normal (if abnormal, will need a CT Scan or MRI). It’s our history that makes the diagnosis.
Identifying Common Causes of Acute Headache
We ask questions for each of our diagnostic possibilities, & examine as indicated:
- Nasal congestion, sneezing, one-sided facial pressure (Allergic Rhinitis, Sinusitis)
- Pain / tenderness with neck movement (Neck Strain / Sprain)
- New medication use, drug use — suspect it as the cause
- Anything going on in life (Stress, Anxiety, Depression, etc)
We keep in mind the possibility of first-episode Migraine, which we discuss under “Recurrent Headaches“. If that seems possible, we offer pain relief (typical migraines only last a few days). We NEVER confidently diagnose “migraine” on the first episode. If everything else seem unlikely, we similarly discuss pain medication if desired, & schedule follow-up.
No firm diagnosis, but no red flags suggesting anything ominous. Headaches are common, often due to unidentified stressors. As for most conditions, time will tell. We reassure the patient there’s no indication of anything serious, basic pain medications can help, but to return if symptoms get worse.
See Acute Headache — Full Text for more in-depth explanations and discussions.