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Diseases

Evaluation of acute headache in adults

OVERVIEW

  • Summary
  • Urgent Considerations
  • Etiology

DIAGNOSIS

  • Differential Diagnosis
  • Diagnostic Approach

IMAGES

  • Library

REFERENCES

  • Citations
  • Credits

Summary

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Headache is pain localized to any part of the head, behind the eyes or ears, or in the upper neck. In the US in 2021, 6.2% of women and 2.2% of men reported being bothered a lot by headache or migraine in the past 3 months.[1]
Diagnostic clues should be derived primarily from history. Hallmark physical signs are often absent, and many physical findings are nonspecific. The majority of patients presenting with acute headache have a benign diagnosis, but a high index of suspicion should be maintained for life-threatening causes of headache.[2]
content by BMJ Group
Last updated

Citations

    Key Articles

    • National Institute for Health and Care Excellence. ​Headaches in over 12s: diagnosis and management. Jun 2025 [internet publication].​[Full Text]

    • American College of Radiology. ACR appropriateness criteria®: headache. 2022 [internet publication].[Abstract][Full Text]

    • Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.[Full Text]

    Referenced Articles

    • 1. QuickStats: percentage* of adults aged ≥18 years who have been bothered a lot by headache or migraine in the past 3 months,(†) by sex and age group - national health interview survey, 2021(§). MMWR Morb Mortal Wkly Rep. 2023 Jun 2;72(22):611.[Full Text]

    • 2. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. 1997 Dec;54(12):1506-9.[Abstract]

    • 3. Chinthapalli K, Logan AM, Raj R, et al. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond). 2018 Oct;18(5):422-7.[Abstract][Full Text]

    • 4. Devenney E, Neale H, Forbes RB. A systematic review of causes of sudden and severe headache (thunderclap headache): should lists be evidence based? J Headache Pain. 2014 Aug 14;15(1):49.[Abstract][Full Text]

    • 5. Flores-Sánchez BC, Tatham AJ. Acute angle closure glaucoma. Br J Hosp Med (Lond). 2019 Dec 2;80(12):C174-9.[Abstract]

    • 6. Renton BJ, Bastawrous A. Acute angle closure glaucoma (AACG): an important differential diagnosis for acute severe headache. Acute Med. 2011;10(2):77-8.[Abstract]

    • 7. Locker TE, Thompson C, Rylance J, et al. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache. 2006 Jun;46(6):954-61.[Abstract]

    • 8. KoÇ G, Metİn KM, AkÇay BD, et al. Relationship between apnea-hypopnea index and oxygen desaturation in REM-sleep period and morning headache in patients with obstructive sleep apnea syndrome. Noro Psikiyatr Ars. 2020 Dec;57(4):294-8.[Abstract][Full Text]

    • 9. National Institute for Health and Care Excellence. ​Headaches in over 12s: diagnosis and management. Jun 2025 [internet publication].​[Full Text]

    • 10. Goldstein JN, Camargo CA Jr, Pelletier AJ, et al. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006 Jun;26(6):684-90.[Abstract][Full Text]

    • 11. Kelly AM, Kuan WS, Chu KH, et al. Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study. Headache. 2021 Nov;61(10):1539-552.[Abstract]

    • 12. McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.[Abstract][Full Text]

    • 13. Carter E, McGill F. The management of acute meningitis: an update. Clin Med (Lond). 2022 Sep;22(5):396-400.[Abstract][Full Text]

    • 14. American College of Radiology. ACR appropriateness criteria®: headache. 2022 [internet publication].[Abstract][Full Text]

    • 15. Hoh BL, Ko NU, Amin-Hanjani S, et al. 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2023 Jul;54(7):e314-70.[Abstract][Full Text]

    • 16. Polmear A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? a systematic review. Cephalalgia. 2003 Dec;23(10):935-41.[Abstract][Full Text]

    • 17. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Headache; Godwin SA, Cherkas DS, Panagos PD, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2019 Oct;74(4):e41-74.[Abstract][Full Text]

    • 18. Buscot MJ, Chandra RV, Maingard J, et al. Association of onset-to-treatment time with discharge destination, mortality, and complications among patients with aneurysmal subarachnoid hemorrhage. JAMA Netw Open. 2022 Jan 4;5(1):e2144039.[Abstract]

    • 19. Galea JP, Dulhanty L, Patel HC, et al. Predictors of outcome in aneurysmal subarachnoid hemorrhage patients: observations from a multicenter data set. Stroke. 2017 Nov;48(11):2958-63.[Abstract]

    • 20. Mollan SP, Spitzer D, Nicholl DJ. Raised intracranial pressure in those presenting with headache. BMJ. 2018 Oct 4;363:k3252.[Abstract]

    • 21. Kernick DP, Ahmed F, Bahra A, et al. Imaging patients with suspected brain tumour: guidance for primary care. Br J Gen Pract. 2008 Dec;58(557):880-5.[Abstract][Full Text]

    • 22. British Association For The Study Of Headache. National headache management system for adults​ 2019. 2019 [internet publication].[Full Text]

    • 23. Ashina S, Terwindt GM, Steiner TJ, et al. Medication overuse headache. Nat Rev Dis Primers. 2023 Feb 2;9(1):5.[Abstract]

    • 24. American College of Radiology. ACR appropriateness criteria; imaging of suspected intracranial hypotension. 2024 [internet publication].[Full Text]

    • 25. Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: an evidence-based analysis. Ont Health Technol Assess Ser. 2010;10(26):1-57.[Abstract][Full Text]

    • 26. Munoz-Ceron J, Marin-Careaga V, Peña L, et al. Headache at the emergency room: etiologies, diagnostic usefulness of the ICHD 3 criteria, red and green flags. PLoS One. 2019;14(1):e0208728.[Abstract]

    • 27. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.[Full Text]

    • 28. Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. 2006 Oct 24;67(8):1492-4.[Abstract]

    • 29. Arendt K, Demaerschalk BM, Wingerchuk DM, et al. Atraumatic lumbar puncture needles: after all these years, are we still missing the point? Neurologist. 2009 Jan;15(1):17-20.[Abstract]

    • 30. Nath S, Koziarz A, Badhiwala JH, et al. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. 2018 Mar 24;391(10126):1197-204.[Abstract]

    • 31. Rochwerg B, Almenawer SA, Siemieniuk RAC, et al. Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline. BMJ. 2018 May 22;361:k1920.[Abstract][Full Text]

    • 32. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006 Nov;82(973):713-6.[Abstract][Full Text]

    • 33. Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, et al. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2016 Mar 7;(3):CD009199.[Abstract][Full Text]

    • 34. Medina LS, D'Souza B, Vasconcellos E. Adults and children with headache: evidence-based diagnostic evaluation. Neuroimaging Clin N Am. 2003 May;13(2):225-35.[Abstract]

    • 35. Sandrini G, Friberg L, Coppola G, et al. Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Eur J Neurol. 2011 Mar;18(3):373-81.[Abstract]

    • 36. National Institute for Health and Care Excellence. Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. Nov 2022 [internet publication].[Full Text]

    • 37. Walton M, Hodgson R, Eastwood A, et al. Management of patients presenting to the emergency department with sudden onset severe headache: systematic review of diagnostic accuracy studies. Emerg Med J. 2022 Nov;39(11):818-25.[Abstract][Full Text]

    • 38. Dubosh NM, Bellolio MF, Rabinstein AA, et al. Sensitivity of early brain computed tomography to exclude aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Stroke. 2016 Mar;47(3):750-5.[Abstract][Full Text]

    • 39. Ferguson C; College of Emergency Medicine. Guideline for the management of lone acute severe headache. December 2009 [internet publication].[Full Text]

    • 40. Park HR, Lee KS, Shim JJ, et al. Multiple Densities of the Chronic Subdural Hematoma in CT Scans. J Korean Neurosurg Soc. 2013 Jul;54(1):38-41.[Abstract][Full Text]

    • 41. Kidwell CS, Wintermark M. Imaging of intracranial haemorrhage. Lancet Neurol. 2008 Mar;7(3):256-67.[Abstract]

    • 42. Kao LW, Nanagas KA. Toxicity associated with carbon monoxide. Clin Lab Med. 2006 Mar;26(1):99-125.[Abstract]

    • 43. Acquired temporomandibular disorders in infants, children, and adolescents. Pediatr Dent. 2018 Oct 15;40(6):366-72.

    • 44. American Association of Oral and Maxillofacial Surgeons. ​Clinical condition statements: temporomandibular disorders. 2017 [internet publication].[Full Text]

    • 45. Larheim TA, Abrahamsson AK, Kristensen M, et al. Temporomandibular joint diagnostics using CBCT. Dentomaxillofac Radiol. 2015;44(1):20140235.[Abstract]

    • 46. Krishnamoorthy B, Mamatha N, Kumar VA. TMJ imaging by CBCT: current scenario. Ann Maxillofac Surg. 2013 Jan;3(1):80-3.[Abstract]

    • 47. Hellmich B, Agueda A, Monti S, et al. 2018 update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020 Jan;79(1):19-30.[Abstract]

    • 48. Mackie SL, Dejaco C, Appenzeller S, et al. British society for rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology (Oxford). 2020 Mar 1;59(3):e1-23.

    • 49. Mollan SP, Paemeleire K, Versijpt J, et al. European Headache Federation recommendations for neurologists managing giant cell arteritis. J Headache Pain. 2020 Mar 17;21(1):28.[Abstract]

    • 50. Dejaco C, Ramiro S, Bond M, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update. Ann Rheum Dis. 2023 Aug 7: ard-2023-224543.[Abstract]

    • 51. Maz M, Chung SA, Abril A, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the management of giant cell arteritis and takayasu arteritis. Arthritis Rheumatol. 2021 Aug;73(8):1349-65.[Abstract]

    • 52. Ponte C, Grayson PC, Robson JC, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Arthritis Rheumatol. 2022 Dec;74(12):1881-9.[Abstract]

    • 53. ​Centers for Disease Control and Prevention. CDC DENV-1-4 real-time RT-PCR assay for detection and serotype identification of dengue virus. Jun 2023 [internet publication].[Full Text]

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