Acute Headache Differential Diagnosis

Acute Headache Differential Diagnosis can seem very complicated, as there are over 14 chapters in the International Headache Society Classification. Each chapter has about a dozen different headache diagnoses to remember!

In acute medical admissions, it is possible to provide a simple differential diagnosis based upon some key features from initial assessment:

  1. Is the the the first headache you have ever experienced?
  2. From the start of you headache until it got to its worst.. how long did it take?
  3. What are the vital signs (Temperature, blood pressure, respiratory rate and pulse rate)?

5 major types of acute headache disorder - slide from lecture

When we surveyed our own practice in Northern Ireland, we found that new onset persistent headaches were the most frequent headache type (57%). We compared accident and emergency to those that are triaged to be admitted to the medical admissions unit, and found that many of these new onset headaches are managed in A&E, usually with a referral to re-attend their general practitioner.

The relative frequency of each headache presentation in the acute medical admissions unit is:

  1. Thunderclap Headache 15%
  2. Headache and Fever 15%
  3. Headache with Focal Neurology 22%
  4. New Onset Persistent Headache 19%
  5. Chronic Headache Disorder 28%

Acute Headache Management and Disposal

From these surveys we found that a minority of headaches presenting to A&E were subject to brain imaging (8%), but that those who did triage through to the Medical Admissions Unit were much more likely to have a CT Brain (77%).

In fact only 11% had no investigations once they reached the medical admissions unit, which proves the point that these cases are difficult and in the face of clinical uncertainty investigation can be helpful.

(Thanks to Dr Mark Roberts, Dr Orla Gray, Dr Seamus O'Reilly, Dr Philip Murphy and Dr Mike Gibbons for their help with these surveys)

The numeric breakdown of different headache types. Each type is roughly equal in frequency once admitted to medical unit

After assessment, most A&E cases are referred back to their general practitioner (over two-thirds), and very few cases are referred from A&E to neurologists.

Following discharge from the medical admissions unit about one third were referred for review at the neurology out-patient clinic.

Most people with acute headache do not require hospital follow-up but are managed by their general practitioner The person referred from medical admissions unit to neurosurgery had a subarachnoid haemorrhage, and the neurology unit referral was for treatment of a recurrent venous sinus thrombosis. Go Back to Acute Headache from Acute Headache Differential Diagnosis

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