Approach to Headache and Facial Pain
Headache
Usually benign; occasionally manifestation of serious illness.
Prevalence: occasional headaches, nearly 100% of population; severe headaches at least once a year, 40%.
General Principles
Quality
Most headaches dull, deeply located, aching.
Sharp, jabbing (ice-pick like): usually benign headache.
Throbbing, “tight”: nonspecific; reflect general head pain mechanisms.
Intensity
Little diagnostic value. Response to placebo (30%) not helpful in diagnosis. Headache due to brain tumor usually not severe.
“Worst headache of my life”: characteristic of subarachnoid hemorrhage, but most frequently due to migraine.
Location
Occasionally informative. Temporal arteritis: local scalp tenderness, after age 60, malaise, high ESR. Posterior fossa lesion: occipito-nuchal headache. Supratentorial lesions: frontotemporal pain. Multifocal head pain: usually benign.
Time-Intensity Relationship
Ruptured aneurysm: pain peaks in an instant (thunderclap).
Cluster headache: 3- to 5-minute peak, 45-minute plateau, then tapers off. Migraine: build-up over hours, maintained for several hours. Brain tumor: sleep disruption.
Associated Factors
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