Secondary headaches are due to a structural brain lesion (e.g., tumor), increased intracranial pressure (e.g., tumor or hydrocephalus), a meningeal process (e.g., meningitis or subarachnoid hemorrhage), or systemic illness (e.g., temporal arteritis). These processes produce headache due to irritation of pain-sensitive intracranial (e.g., meninges) or extracranial (e.g., scalp) structures.
Primary headaches are not due to a structural brain, meningeal, or systemic process. Common primary headaches include migraine, tension, and cluster headache.
Always ask about the onset and time course of development of the headache. Suddenness of headache onset (i.e., an explosive onset developing over seconds) strongly suggests the possibility of aneurysmal subarachnoid (or other intracranial) hemorrhage. Gradually progressive headaches (e.g., over days, weeks, or months) suggest the possibility of intracranial mass lesion, hydrocephalus, or other causes of increased intracranial pressure.
Ask about symptoms of meningeal irritation (meningismus), such as neck stiffness or photophobia that may be seen in some patients with subarachnoid hemorrhage or meningitis (photophobia is also a common symptom of migraine).
Ask about any focal neurologic symptoms, such as weakness, double vision, sensory symptoms, or gait problems, that would suggest a focal intracranial lesion. Nausea and vomiting, although nonspecific and common in migraine, can be a symptom of increased intracranial pressure or lesions in the cerebellum.
In any elderly patient with new-onset headaches, consider the possibility of temporal arteritis. Ask about discomfort or fatigue in the jaw with chewing (jaw claudication), scalp tenderness, transient monocular vision loss,
constitutional symptoms, or diffuse muscle ache (suggestive of polymyalgia rheumatica).
TABLE 45-1 Symptoms of Some Serious Causes of Headache
Cause of Headache
Time Course
of Headache
Typical Associated Symptoms (in
Addition to Headache)
Subarachnoid hemorrhage
Sudden onset
Neck pain and stiffness, photophobia
Meningitis
Subacute onset
Fever, neck pain and stiffness, photophobia, sometimes rash (the presence of confusion or aphasia suggests encephalitis)a
Intracranial hemorrhage; intraventricular hemorrhage
Sudden onset, may be progressive
Focal neurologic symptoms, nausea and vomiting, gait dysfunction (especially with cerebellar hemorrhage)
Mass lesion
Gradually progressive
Focal neurologic symptoms, nausea and vomiting
Hydrocephalus
Gradually progressive
Nausea and vomiting, possibly gait dysfunction
Pseudotumor cerebri (idiopathic intracranial hypertension)
Gradually progressive, or waxing and waning
Transient visual obscurations, pulsatile tinnitus, obesity
Temporal arteritis
Waxing and waning
Monocular vision loss (transient or persistent), scalp tenderness, jaw claudication, fevers, muscle aches
a Meningeal processes can also cause cranial nerve or radicular symptoms due to location of these structures within the subarachnoid space; this most commonly occurs in chronic (e.g., infectious, neoplastic, or inflammatory) meningitides.
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