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Differential diagnosis: Acute headache

Primary

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Secondary – intracranial

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Other secondary intracranial differentials = encephalitis, cerebral abscess, tumour, pituitary apoplexy, subdural haematoma, extradural haematoma, spontaneous intracranial hypotension, reversible cerebral vasoconstriction syndrome, carotid/vertebral artery dissection

Secondary – extracranial

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Other secondary extracranial differentials = drugs (e.g. nitrates, PPI, Ca2+ antagonists, caffeine, analgesia overuse, hormones), drug withdrawal, carbon monoxide poisoning, post-traumatic, Paget’s disease, hypoxia, cervical spondylosis, otitis media, dental causes

Test yourself! What is the most likely cause of headache in the following scenarios? What is the investigation of choice?

A 34 year old taking the combined oral contraceptive pill presents with a worst ever headache. It has progressed over 2 weeks and is much worse when she coughs or lies down. She has noticed some diplopia.

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A 44 year old male presents with a severe headache, rated as 10/10. It is occipital and reached maximum intensity within 1 minute.

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17 year old female presents with a severe headache that built up over the last 24 hours. She is nauseous, vomited twice and needs to lie down in a dark room as she is sensitive to light. Moving around makes the headache worse.

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A 50 year old presents with a headache associated with a fever and new onset confusion.

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A 46 year old female who had breast cancer treated 4 years ago and is in remission presents with a headache for 3 weeks. It is worse in the morning and when she bends over. She noticed her left arm is slightly more clumsy over the last week.

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A 31 year old female with BMI 36 has a headache for 4 weeks. It is worse with coughing, bending, and sneezing. Her vision is blurred.

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Try an OSCE station

  1. Acute assessment – headache
  2. Subarachnoid haemorrhage history
  3. Migraine with aura history
  4. Find more here
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