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differential diagnosis of headache classification primary secondary
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headache red flags secondary causes dangerous life-threatening
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Differential Diagnosis of Headache
Headaches are classified by the International Classification of Headache Disorders, 3rd edition (ICHD-3) into Primary and Secondary headache disorders. The key initial step is ruling out secondary (dangerous) causes.
🔴 RED FLAGS (SNOOP4 Mnemonic) — Warrant Urgent Workup
| Flag | Concern |
|---|---|
| Systemic symptoms (fever, weight loss, HIV) | Meningitis, malignancy |
| Neurological deficits | Intracranial mass, stroke |
| Onset sudden/thunderclap | Subarachnoid hemorrhage |
| Older age (>50, new headache) | Giant cell arteritis, malignancy |
| Progressive worsening | Intracranial hypertension, mass |
| Papilledema | Raised ICP |
| Positional headache | CSF leak, Chiari malformation |
| Precipitated by Valsalva/exertion | Arnold-Chiari, SAH |
I. PRIMARY HEADACHE DISORDERS
1. Migraine
- Unilateral, throbbing, moderate-severe intensity
- Associated: nausea/vomiting, photophobia, phonophobia
- Duration: 4–72 hours
- With aura (classical): visual scotoma, scintillating lights, paresthesia precede headache
- Without aura (common): most frequent type
- Triggered by stress, hormonal changes, certain foods, sleep disruption
2. Tension-Type Headache (TTH)
- Bilateral, pressing/tightening (band-like), mild-moderate severity
- No nausea, vomiting, photophobia/phonophobia (≤1 feature)
- Duration: 30 min – 7 days (episodic); >15 days/month (chronic)
- Most common primary headache worldwide
3. Cluster Headache
- Strictly unilateral, periorbital/temporal, excruciating (boring/stabbing)
- Autonomic features ipsilateral: lacrimation, nasal congestion, ptosis, miosis
- Duration: 15–180 min; occur in clusters (bouts of weeks-months)
- Patient is restless/agitated (unlike migraine where patient prefers rest)
- Male > Female (5:1)
4. Trigeminal Autonomic Cephalalgias (TACs)
| Feature | Cluster | PH (Paroxysmal Hemicrania) | SUNCT |
|---|---|---|---|
| Duration | 15–180 min | 2–30 min | 5–250 sec |
| Frequency | 1–8/day | >5/day | Up to 200/day |
| Autonomic features | Yes | Yes | Yes |
| Key treatment | O₂, Sumatriptan | Indomethacin | Lamotrigine |
5. New Daily Persistent Headache (NDPH)
- Sudden onset of daily headache in a person with no prior headache history
- Must rule out secondary causes
II. SECONDARY HEADACHE DISORDERS
A. Vascular Causes
| Condition | Clue |
|---|---|
| Subarachnoid Hemorrhage (SAH) | "Thunderclap" — worst headache of life, sudden onset, stiff neck |
| Subdural Hematoma | Elderly/head trauma; progressive dull headache, altered consciousness |
| Hypertensive Headache | BP >180/120 mmHg; occipital, pulsating |
| Cerebral Venous Sinus Thrombosis | Raised ICP, progressive, papilledema; women on OCP |
| Vertebral/Carotid Artery Dissection | Neck pain + Horner's + focal neurology; post-trauma |
| Giant Cell (Temporal) Arteritis | >50 years, tender temporal artery, jaw claudication, raised ESR/CRP |
B. Intracranial Pressure (ICP) Disorders
| Condition | Clue |
|---|---|
| Intracranial mass (tumor/abscess) | Progressive, worse in AM, worsened by Valsalva, papilledema, focal signs |
| Idiopathic Intracranial Hypertension (IIH) | Obese young female, pulsatile tinnitus, papilledema, vision loss; no mass on MRI |
| Low CSF Pressure (Post-LP/spontaneous) | Positional — worse upright, better supine |
C. Infectious Causes
| Condition | Clue |
|---|---|
| Bacterial Meningitis | Fever + neck stiffness + photophobia (Kernig's/Brudzinski's signs) |
| Viral Meningitis/Encephalitis | Milder, altered sensorium in encephalitis |
| Brain Abscess | Focal signs, fever, subacute progression |
| Sinusitis | Facial pain/pressure, worsened by bending forward, nasal discharge |
D. Cervicogenic Headache
- Originates from cervical spine/musculature
- Unilateral, starts at neck, radiates to frontotemporal area
- Precipitated by neck movement
E. Medication & Substance-Related
| Condition | Clue |
|---|---|
| Medication Overuse Headache (MOH) | >15 days/month; overuse of analgesics/triptans ≥3 months |
| Nitrate/vasodilator headache | After nitroglycerin/nitrates |
| Caffeine withdrawal | Bilateral, after caffeine cessation |
| Alcohol ("hangover") | After excess alcohol |
F. Referred Pain
| Condition | Clue |
|---|---|
| Dental/TMJ disorders | Jaw pain, facial pain |
| Glaucoma (acute angle closure) | Periorbital pain, red eye, halos, nausea, raised IOP |
| Otitis Media | Ear pain + headache |
| Trigeminal Neuralgia | Brief, electric-shock-like; triggered by touch/chewing |
G. Systemic/Metabolic
- Hypothyroidism: dull diffuse headache
- Anemia: diffuse, exertional
- Hypoglycemia: frontal, relieved by glucose
- Sleep apnea: morning headache, bilateral, relieved within 30 min of waking
- High altitude (HACE): throbbing, worsened by exertion
H. Post-Traumatic Headache
- Starts within 7 days of head injury; can be persistent (>3 months)
Quick Comparison: Key Primary Headaches
| Feature | Migraine | Tension | Cluster |
|---|---|---|---|
| Location | Unilateral | Bilateral | Unilateral (periorbital) |
| Quality | Throbbing | Pressing | Boring/stabbing |
| Severity | Moderate-severe | Mild-moderate | Severe (suicidal) |
| Duration | 4–72 hr | 30 min–7 days | 15–180 min |
| Nausea/vomiting | Yes | No | Occasional |
| Photo/phonophobia | Yes | ≤1 feature | No |
| Autonomic features | No | No | Yes |
| Patient behavior | Lies still | Normal activity | Restless, pacing |
| Aura | Possible | No | No |
Diagnostic Approach Summary
- History: onset, character, location, duration, frequency, triggers, associated symptoms
- Neurological examination: always
- Red flags → Urgent imaging (CT non-contrast first for suspected SAH/hemorrhage; MRI for most others)
- LP: if SAH suspected and CT is negative
- Blood tests: ESR/CRP (GCA), CBC, glucose, TFTs as indicated
- Tonometry: if acute glaucoma suspected
(Sources: Management of Headache, pp. 9, 30; ICHD-3 criteria)
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