23 year old male complains of an intermittent headache for 3 weeks.

🚩 Red flags
Systemic: Fever, Weight Loss, Cancer, Immunocompromised.
Neurologic: Confusion, Altered mental status, Papilledema, Focal signs, Meningismus, Seizures.
Onset: New (esp age>40yo), Sudden (Thunderclap)
Other: Trauma, Drug use, Onset of headache with exertion, cough or sexual activity.
Previous headache hx with changes in freq, severity, clinical features.


Secondary Headaches

Infection

Vascular

Trauma

Substance use or withdrawal

Metabolic

Psychiatric

Primary Headaches

HPI:
Freq, How many x in a month, Duration
Assoc S: Any N/V?
E/A: Worse with exercise?


Has anything like this happen previously?
Any recent changes in your headaches?
Recent Trauma?
Any recent changes in sleep, exercise, diet?


ROS:
Constitutional: Have you noticed any fever or weight loss?
HEENT: Do you have any trouble with your ears or hearing? Your eyes or vision? Your nose or sinuses? Your throat or voice?
Neuro: Any unusual sensations in your arms or legs? Weakness in your arms or legs? Trouble with balance or walking? Trouble with memory, headaches or dizziness?


PMH
Drug Hx: Recreational drug use?
Family Hx: Migraine?
Social Hx
Lifestyle Risk: Alcohol, Smoking
ROS

  • Lesion in optic pathway: Visual field defects
  • Optic Neuritis: Sudden, severe, unilateral vision loss
  • ↑ICP: Blurring of vision on forward bending of head, headaches upon waking that improve with sitting up, double vision or loss of coordination and balance
  • Intracranial Hypotension (Due to CSF leakage): Relieved with recumbency, Exacerbated with upright posture
  • Tumor: N/V. Worsens with changes in body position (particularly bending over), an aAbnormal neurologic examination, and/or a significant change in prior headache pattern.

SAH

Hx: Sudden severe headache ("Worst headache of my life"). Neck stiffness. N/V.

PE: Mild ↑BP. ↑Temp. Tachycardia. ↑ICP - Loss of pupillary light reflex. Fundoscopy - Papilledema, Retinal hemorrhage. CN III palsy - PCA aneurysm rupture. Hemiparesis - MCA aneurysm/ischemia/trauma.

Bacterial meningitis

Hx: Classic triad (Fever >38ºC, Nuchal rigidity, Altered mental state). Severe generalized headache. Seizures.

PE: Positive Kernig/Brudzinski signs. Nuchal rigidity.

Encephalitis

Hx: Altered mental status. Seizures. Confused. Agitated.

PE: Hemiparesis, CN palsies. ↑↑DTR. Parotitis (Mumps). Grouped vesicles in a
dermatomal pattern (VZV). Ataxia.

Brain abscess

Malignancy

Medication overuse headache