Headaches are among the most frequently named symptoms in general practices.
Guidelines suggest that neuroimaging should be ordered only if a stable headache patient displays localizing neurological symptoms or signs 3).
Countless medical textbooks and journal articles provide insight into and guidance on the clinical diagnosis of headache disorders, and most primary headaches can be diagnosed through careful history and physical examination 4).
Differential diagnosis of severe, acute, paroxysmal headache (25% will have SAH):
Subarachnoid hemorrhage, AKA “warning'headache” or sentinel H/A
There is no subarachnoid blood on CT and LP, which should probably be performed on at least the first presentation to R/O SAH. Earlier recommendations to angiogram these individuals have since been tempered by experience
reversible cerebral vasoconstrictive syndrome (RCVS) (AKA benign cerebral angiopathy or vasculitis): severe H/A with paroxysmal onset ± neurologic deficit.
The most common symptom of idiopathic intracranial hypertension (IIH) is headache.
Headache after lumboperitoneal shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is commonly attributed to intracranial hypotension (IH) due to shunt overdrainage 5).
People with epilepsy experience headaches irrespective of their sex or age. The burden of headaches is very important in patients with epilepsy, since headaches usually cause a moderate or severe burden to their quality of life and suggest a clear clinical need. Clinicians should recognize headache as a common comorbidity of epilepsy, as it may influence antiepileptic drug choice, and may need specific treatment 6).
About 90% of the patients suffer from idiopathic headaches, for example, migraine or tension headaches, which are treated according to guidelines. An acute headache can however also be a symptom of a serious primary disease, such as subarachnoid hemorrhage, arterial dissection, cerebral infarction, cerebral venous thrombosis or acute glaucoma. Patients with suspected symptomatic headaches must be immediately referred to a specialist or hospital for further diagnosis and therapy 7).