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Headache is such a common complaint and can occur for so many different reasons that its proper evaluation may be difficult Headaches of acute onset are discussed in 2 Chronic headaches are commonly due to migraine, tension, or depression, but they may be related to intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, temporomandibular joint dysfunction, sinusitis, hypertension, and a wide variety of general medical disorders Although underlying structural lesions are not present in most patients presenting with headache, it is nevertheless important to bear this possibility in mind About one-third of patients with brain tumors, for example, present with a primary complaint of headache The intensity, quality, and site of pain and especially the duration of the headache and the presence of associated neurologic symptoms may provide clues to the underlying cause Migraine or tension headaches are often described as pulsating or throbbing; a sense of tightness or pressure is also common with tension headache Sharp lancinating pain suggests a neuritic cause; ocular or periorbital icepick-like pains occur with migraine or cluster headache; and a dull or steady headache is typical of an intracranial mass lesion Ocular or periocular pain suggests an ophthalmologic disorder; bandlike pain is common with tension headaches; and lateralized headache is common with migraine or cluster headache In patients with sinusitis, there may be tenderness of overlying skin and bone With intracranial mass lesions, headache may be focal or generalized; in patients with trigeminal or glossopharyngeal neuralgia, the pain is localized to one of the divisions of the trigeminal nerve or to the pharynx and external auditory meatus, respectively Inquiry should be made of precipitating factors Recent sinusitis or hay fever, dental surgery, head injury, or symptoms suggestive of a systemic viral infection may suggest the underlying cause Migraine may be exacerbated by emotional stress, fatigue, foods containing nitrite or tyramine, or the menstrual period Alcohol may precipitate cluster headache Temporomandibular joint dysfunction causes headache or facial pain that comes on with chewing; trigeminal or glossopharyngeal neuralgia may also be precipitated by chewing, and masticatory claudication sometimes occurs with giant cell.

arteritis Cough-induced headache occurs with structural lesions of the posterior fossa, but in many instances no specific cause can be found The timing of symptoms is important Headaches are typically worse on awakening in patients with sinusitis or an intracranial mass Cluster headaches tend to occur at the same time each day or night Tension headaches are worse with stress or at the end of the day The onset of severe headache in a previously well patient is more likely than chronic headache to relate to an intracranial disorder such as subarachnoid hemorrhage or meningitis The need for further investigation is determined by the initial clinical impression A progressive headache disorder, new onset of headache in middle or later life, headaches that disturb sleep or are related to exertion, and headaches that are associated with neurologic symptoms or a focal neurologic deficit usually require cranial MRI or CT scan to exclude an intracranial mass lesion Signs of meningeal irritation and impairment of consciousness also indicate the need for further investigation (cranial CT scan or MRI and examination of the cerebrospinal fluid) to exclude subarachnoid hemorrhage or meningeal infection The diagnosis and treatment of primary neurologic disorders associated with headache are considered separately under these disorders

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Patients frequently complain of poor concentration and other vague nonspecific symptoms, in addition to constant daily headaches that are often vise-like or tight in quality and may be exacerbated by emotional stress, fatigue, noise, or glare The headaches are usually generalized, may be most intense about the neck or back of the head, and are not associated with focal neurologic symptoms When treatment with simple analgesics is not effective, a trial of antimigrainous agents (see Migraine, below) is worthwhile Techniques to induce relaxation are also useful and include massage, hot baths, and biofeedback Exploration of underlying causes of chronic anxiety is often rewarding Local injection of botulinum toxin type A is sometimes helpful, has few systemic adverse effects, and requires only infrequent administration

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Patients often give a family history of migraine Attacks may be triggered by emotional or physical stress, lack or excess of sleep, missed meals, specific foods (eg, chocolate), alcoholic beverages, menstruation, or use of oral contraceptives An uncommon variant is basilar artery migraine, in which blindness or visual disturbances throughout both visual fields are initially accompanied or followed by dysarthria, disequilibrium, tinnitus, and perioral and distal paresthesias and are sometimes followed by transient loss or impairment of consciousness or by a confusional state This, in turn, is followed by a throbbing (usually occipital) headache, often with nausea and vomiting In ophthalmoplegic migraine, lateralized pain often about the eye is accompanied by nausea, vomiting, and diplopia due to transient external ophthalmoplegia The ophthalmoplegia is due to third nerve palsy, sometimes with accompanying sixth nerve involvement, and may outlast the orbital pain by several days or even weeks The ophthalmic division of the fifth nerve has also been affected in some patients Ophthalmoplegic migraine is rare; more common causes of a painful ophthalmoplegia are internal carotid artery aneurysms and diabetes In rare instances, the neurologic or somatic disturbance accompanying typical migrainous headaches becomes the sole manifestation of an attack ( migraine equivalent ) Very rarely, the patient may be left with a permanent neurologic deficit following a migrainous attack

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