Differentiating the Cause of Nonprimary Headaches

treatment plan

Differentiating the Cause of Nonprimary Headaches


Pain is a great motivator. In our field, periocular or head pain drives our patients to see us. Headaches come in a variety of classifications, including asthenopic or vision-related headaches and tension headaches. But the most important type of headache, even though it only represents a small fraction of all headaches, is classified as a nonprimary headache. This type of headache is secondary to some underlying physical disorder.

This article will cover the recognition of critical signs that help to differentiate a benign headache from one that may be the result of a grave, life-threatening condition.

Common Causes

Serious nonprimary headaches can be a result of intracranial hemorrhage, stroke, aneurism, systemic hypertension, brain tumor, cranial arteritis, temporal arteritis, vasculitis, meningitis, cavernous sinus disease or a pseudo-tumor.

The Work-Up

A complete patient history is the single most useful tool in diagnosing head pain. A thorough form of questioning will aid you in gathering the appropriate data. When taking a headache history, it's important to understand which signs or symptoms most strongly indicate a serious underlying condition (Table 1).

TABLE 1:  Symptoms of an Underlying Cause

  • Onset after age 50.
  • A new or different type of headache.
  • Headache described as the worst ever experienced.
  • Headaches that occur more frequently or more severely.
  • Headaches triggered by exertion, coughing or sneezing.
  • Headaches associated with neurological changes (e.g., drowsiness, weakness, loss of coordination, numbness, paralysis or pupillary changes, such as vision loss or diplopia).
  • Presence of stiff neck, fever or papilledema.

Occasionally, certain symptoms, such as those identified in Table 2, require special tests like neuroimaging. But before referring patients for these tests, certain simple tests should be performed, including: a thorough, dilated eye examination; a screening visual field; a blood pressure check; a Complete Blood Count (CBC); a Erythrocyte Sedimentation Rate (ESR) check and a C-reactive protein test if temporal arteritis is suspected.

TABLE 2:  Test Indicators

  • Decreased alertness or cognition.

  • Recent history of head trauma.
  • Onset with exertion, cough or straining.
  • Symptoms getting steadily worse.
  • Stiff neck.
  • Neurological deficits.
  • First headache in patient over 50 years old or their "worst headache ever."
  • Headache doesn't fit a defined pattern.

Preventative Measures

When it comes to headaches, a thorough and methodical evaluation will save time and prevent misdiagnosis and unnecessary referrals and tests.

It's very important to refrain from using analgesic medications until you obtain a definitive diagnosis. The premature administration of these drugs may mask symptoms of an underlying disease and delay the diagnosis and proper management of the patient's condition.

My next column (March 2000) will discuss the evaluation and management of vascular headaches.

Dr. Onofrey, editor and author of various ophthalmic texts, practices in Albuquerque, New Mexico.