Differential Diagnosis

  • Vascular: bleed (epidural, subdural, subarachnoid, intraparenchymal), clot (venous sinus thrombosis), spasm (migraine), HTN
  • Infectious: meningitis, encephalitis, sinusitis, mastoiditis, dental, intracranial abscesses
  • Neoplasm and increased ICP (pseudotumor cerebri)
  • Drugs
  • Inflammatory: temporal arteritis, vasculitides
  • Congenital
  • Autoimmune
  • Trauma
  • Endocrine
  • Other
    • Ocular: glaucoma, optic neuritis
    • MSK: TMJ syndrome, tension-type, C-spine disorders
    • Cranial neuralgias
    • Carbon monoxide exposure

Deadly (or blinding) headaches

  • Meningitis
  • Subarachnoid hemorrhage
  • Venous sinus thrombosis
  • Temporal arteritis
  • Acute angle closure glaucoma



  • Onset
    • Females – biphasic onset: late teens, late 40s
    • Males – biphasic onset: early childhood, 20s
  • Presentation
    • Classic: with aura (scintillating scotoma – wavy lines, flashing lights, expanding blind spot) lasting ~30 minutes
    • Common: without aura
    • Unilateral (sometimes bifrontal) – esp. at onset
    • Pounding/throbbing
    • Photophobia and/or sonophobia
    • Nausea and/or vomiting
    • No positional component
    • Usually lasts until patient falls asleep (hrs – day
  • Triggers
    • Stress, allergies
    • Food (nitrates, chocolate, caffeine)
    • EtOH
    • Smoking
    • Menses
    • Weather
    • Lack of sleep
  • Treatment
    • ABC’s
    • Dark quiet room
    • Fluids
    • Abortive therapy
      • Metoclopramide 10-20mg IV
      • NSAIDS
      • DHE 0.5 mg IV given over 2-3 minutes (following Maxeran and fluid bolus – contraindicated if use of triptans w/i 24hr, heart disease or HTN, pregnancy)
      • Prochlorperazine (Stemetil) 10mg IV
      • Chlorpromazine (Largactil) 0.1-0.2mg/kg IV with NS bolus
    • Rescue pain
      • Meperidine 75-100mg IM with antiemetic
      • Morphine 7.5-10mg IM with antiemetic
      • Codeine, oxycodone
      • ASA, Tylenol, Ibuprofen
    • Prophylaxis
      • Beta blockers or CCB
      • Tricyclics
      • Triptans

Assessment of potential bleeds

  • ABCs
    • Intubate a GCS ≤ 8
    • IV access, O­2
    • C-spine precautions if traumatic
    • Standard labs
    • Monitor neurovitals and vitals
  • Emergent CT without contrast (95% sensitive of SAH at 24hr… 50% by 1 wk)
  • LP (xanthochromia = SAH; RBCs)
  • Hx – sentinel bleed in prior 2-3wks (SAH)
  • NeuroSx consult
  • Bedrest, elevate head of bed 30o (risk of re-bleed greatest in 24hr)
  • Control pain and vomiting (especially)
  • Rx
    • Antiemetics
    • Antivasospam agents
    • Seizure prophylaxis
    • Antihypertensives

Subdural hematomas: tearing of the bridging veins between the cortex and the dural sinuses (elderly and alcoholics)

Acute Presentation:

  • Level of consciousness: altered or deterioration – may have a lucid interval
  • Common symptom: headache, vomiting,  lethargy
  • Unilateral weakness – use pronator drift to assess
  • Pupils: asymmetry is a late finding (note: hematoma will be on same side as dilated pupil)

Sub acute/Chronic Presentation:

  • Headaches, worsened by changing position
  • Cognitive or personality changes
  • New onset of seizures
  • New hemiparesis or weakness

Acute subdural: diagnosed within 5 days and hyperdense on CT

Sub-acute subdural: diagnosed between 5 and 21 days and is isodense then hypodense on CT

Chronic subdural: diagnosed after 21 days, hypodense on CT

1 thought on “Headache”

  1. Hi.. Excellent notes. I will be taking the NAC OSCE this March. In about a month and a half. I have already passed the USMLE STEP 2cs. I also reviewing from First Aid for Step 2CS. I’m an aspiring resident and hope this exam will be a nice bonus on my application. Your notes are very concise and a nice addition to my other resources.

    I will gladly support you and your team by paying the $10.00. Thank you keeping the cost to a minimum. As you may know, med school and residency applications are not cheap.

    Best Regards.


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