Disclaimers: User guides for managing a headache, distinguishing high risk from low risk. But obviously keep a physician involved in your headache or the headache of a loved one. If your headache is over a day old or the worst headache of your life, I have to recommend you go to the emergency room. At least try to contact your doctor for care. Don’t try to self medicate with prescription medications, especially controlled substances, for headache management ever. Always care for your headache under the direct guidance of a physician.

About Headaches

Classically, a headache that has been there for over 48 hours in a patient that doesn’t have a history of headaches is going to be something that needs acute care. Classically, headaches that worsen throughout the day, reaching their peak every evening, night after night, are the headaches we experience with malignancy (cancer). Classically, if you can ever say your headache is the worst headache of your life, then it is more likely than any of your headaches to be something that needs immediate medical care. Classically, any headache associated with fever and or neck pain should raise an interest in meningitis or encephalitis as possibilities for an underlying cause.

Those are the bad ones. What about the regular ones.

Probably the two most common are muscle tension headaches and sinus headaches.

Muscle tension headaches are mostly at the back of your head associated with neck and or back spasms. They respond nicely to MASSAGE, Tylenol, Advil. Chiropractic care can help. I’m a big big believer in acupuncture as well.

Types of Headaches

So what are the big pearls when it comes to headaches, common and not common, non-life-threatening, and dangerous if missed. I will hit the different types of headaches in and bring up the dangerous ones as they come up based on similarities of presentation.

Different type of headaches: vascular, muscular, inflammatory, infectious, ocular including glaucoma. Basically, think everything in your head.

So of course that includes things that irritate the dura, the encasing of the brain… Because the dura, or rather pressure on the dura, will give you a headache. So a tumor encroaching on the dura like a pituitary adenoma will hurt. That would be a significant diagnosis not to mess up and will require blood work and usually a CT.

Trouble is, tumors don’t generally cause headaches until they produce enough pressure on the dura to cause a headache. Or edema where there is enough of a mass effect because the tumor is large enough to encroach on the dura this way. Or the tumor is bleeding. Anytime there is bleeding in the brain, it causes a headache. So one type of stroke, the bleeding stroke as opposed to the brain death ischemic stroke from a lack of blood supply, will produce headache because the blood is irritating to the ventricles of the brain. Those types of bleeding tumors will produce a headache.

So let’s go on to other cause, causes of headaches other than tumors.

There are plenty of structures outside the brain, the sinuses, muscles, the vessels, the eyeballs, That can give you a headache.

Sinus Headaches

Sinus headaches are in your face. They may even be associated with ear pain. They respond nicely to Sudafed and Afrin. Stick to the regular adult doses if you are an adult; stick to the regular children doses if you are caring for a child. Don’t use pseudoephedrine or Afrin for more than a day ever please. Don’t use either of these if you have blood pressure problems (i.e., blood pressure lability or you use blood pressure medications).

Vascular Headaches

Start with the vessels. They are known as vascular headaches. They are also known as the migraines. About 20% of them are what is called prodromal, meaning you can tell the headache is coming before the headache starts.

These patients tend to know their migraine history. So that is always a clue. The big pearl with migraine headaches in treatment is that medications like Imitrex, now generic, works great for the spastic component of the vascular (Migraine) headache. But there’s also an inflammatory component to a migraine (Vascular) headache. So as soon as one is coming on, you should take an Imitrex, and right in the same stomach, you should take four ibuprofen 200 mg, all with food. This combination of anti-spasm and anti-inflammatory should really take care of vascular headache (a migraine).

Malingering patients looking for narcotics often complain of migraines. Migraines and chronic headaches are the worst, well one of the two worst, chronic pain reasons for being on opiates chronically. Chronic headaches and chronic abdominal pain are strongly frowned upon for chronic opiate use.

Doctors now have access to a PMP, physician monitoring program, in almost every state. Looks like we’re watching the physicians’ prescribing habits with them is what we are doing, but we are more watching what the patients are doing, how many doctors they have been to in a month, if they just saw a doctor for this for opiates yesterday, and so forth, like that.

So that’s another big pearl. And that is, if a doctor has just seen him for the headache 12 to 24 hours ago, it’s probably not a migraine. Due to malingering or something like opiate withdrawal or it’s something that’s nothing to do with migraines or opiate withdrawal at all. It may be one of the more life-threatening headaches like a stroke.

Hemiplegic Migranes

Hemiplegic migraines are a important type of migraine headaches. The patient cannot move on one side, often the left. They are given TPA because the emergency room doctor suspects a stroke. There are no MRI or CT findings, though, Because they are in actuality just migraine or vascular headaches. They repeat this presentation a few weeks later, and everybody becomes aware of them – it has probably been a migraine. TPA is usually repeated, correct treatment for stroke. Neurology referral is of course indicated. But the biggest Pearl for migraines is: no opiates for migraines.

Cluster Headaches

Cluster headaches. Male over female predominance. It comes in clusters, hence the name. Nasal congestion, rhinorrhea, lacrimation, Occasionally Horner’s syndrome. Treatment in emergency apartment includes oxygen because a tiny area of your brain is not getting enough oxygen, hence the presentation with a stabbing spike through your brain is a common complaint. Emergency physicians will also use clipper tricks like lighter port lidocaine intranasally. Many of the migraine medications work for cluster headaches. Calcium channel blocker‘s are famous. Steroids in what is usually prescribed is a Medrol dose pack work for cluster headaches as well.

And here are some nice pearls about cluster headaches. Cluster headaches arise from a tiny area deep inside your brain that is not getting enough oxygen. So, if you breathe oxygen from an oxygen tank in a higher concentration than you get from room air, those headaches will go away. And that’s actually a nice way of securing that diagnosis. But not everybody has oxygen at their house. One way you can mimic oxygen blow by is by getting into a car, and cracking all your windows as you go for a drive. This is in fact what is advised for taking a patient to the emergency room if there’s ever an emergency because oxygen helps so many acute things. Drive them safely to the emergency room without delay “with your windows cracked“. Cracking your windows It’s a nice trick for mimicking blow by oxygen.

So let’s say you have a headache that does not seem throbbing, so not migrainous. You don’t have access to oxygen. So you get in your car, drive around with the windows cracked, and it goes away. You probably have a cluster headache. Of course, you’re not going to live in your car riding around to get blow by oxygen for your headaches. You’re going to need other care. Prescription medications that help cluster headaches include steroids and calcium channel blocker‘s. Some patients require stronger control. It’s always nice to avoid opiates because these headaches aren’t going to go away, if you’re gonna continue throwing opiates at them, you will get addicted to opiates. So not the right choice.

Temporal Arteritis Headache

Temporal arteritis. Female more than male. The elderly. The temple artery which runs over the years is tender. The inflammation they’re very near your job can make your mandible very stiff. One of the branches of the temporal artery, the ophthalmic artery, can become involved. If that gets inflamed, it can lead to blindness. So this is one of those headaches that absolutely cannot be missed. There is an ongoing debate as to whether not you want to mask the diagnosis by giving steroids prior to the biopsy. Absolutely! If the steroids first. worry about a biopsy later. Treatment is important. You are avoiding blindness your folks. All the academics and speculating can go out the window on this one docs. Treat. Steroids. Ophthalmology consult. Then they or you can consult vascular for a vascular biopsy to get the diagnosis. Indicators of inflammation like Cedric rate, sedimentation rate which assesses how quickly your red blood cells settle (so said rate goes up with inflammation because the blood is more viscous and things are not settle in quickly) and CRP (secreted by vascular cells, so remember this is a vasculitis, they are inflamed, so the CRP is going to be up because the vessels are inflamed) are usually up. But 20% of the time they are not! So don’t hang your hat on that. Again, trial of steroids if you suspect it.

Glaucoma Headache

Glaucoma. Headache that presents with a steamy, dilated, unresponsive pupil. It’s all about the eye for these folks. They have trouble seeing out of the painful eye. And, it is fairly sudden. Emergency room physicians know to immediately start IV Acetazolamide. It lowers severely increased intraocular pressure (often exceeds 20 mm Hg). So they get beta blockers like Timolol drops which block sympathetic nervous output. This allows the pupil to constrict and relieves the discomfort.

Cranial Cervical Arterial Dissections Headache

Cranial cervical arterial dissections. Now we are getting into probably one of the most important of the high-risk headaches that absolutely can’t be missed. Any sudden deceleration trauma, bungee jumping, sneezing, motor vehicle accidents, can produce dissection in these arteries, a splitting down of the artery wall. Neurological findings on exam occur much later, so they are often missed. The intimal flap of the artery that tears is a great place for emboli to form. Those emboli go on to fall off and move in the bloodstream towards a narrower artery downstream. That blocked artery leads to an ischemic stroke, the type of a stroke in which you lose a portion of brain. So, even though there’s drama and a dissecting Marjorie, this is one arterial dissection weren’t actually correct to give blood thinners, TPA. Because the TPA will block the emboli process.

So: this is the form of dissection of an artery us giving the patient anticoagulants is CORRECT. Usually giving anticoagulants for dissections like an aorta or trauma of most kinds is the wrongest thing you can do. In this setting, though, if the diagnosis is made, anticoagulation is the treatment of choice to prevent that embolus formation and subsequent stroke many hours later.

So beware of that “muscle tension headache secondary to neck sprain after a car wreck“ presentation. It could be cerebral vertebral arterial dissection!

Basilar Vertebral Artery Stroke Headache

Basilar vertebral artery stroke. And I’m going to do a full topic on stroke. But in a nutshell, this is one type of stroke that classically early on presents with a stable headache. As stated above, any arterial occlusion in the brain is a stroke. Strokes are also known as a cart cerebrovascular accident (CVA). Vertebral artery stroke is just one of the many kinds of stroke you can have in your brain. It is a very principal artery. And a vertebral artery stroke produces a headache. This is one of those headaches you do not want to miss. It quickly produces what is known as the “killer D’s”. So, here’s your pneumonic for the day:


  • Dizziness
  • Death
  • Dysphasia
  • Dysarthria
  • Diplopia

A basilar vertebral artery stroke is occluding the vertebral artery, a very principal artery. All emergency physicians know about the killer D’s when they present with a stroke presentation. But MDs be keenly aware of it presenting early with just a headache, and moving towards an evolution that includes the killer D’s, often times right before their very eyes. They know not to miss it. Imaging of choice is a CTA, arterial CAT scan.

Pseudotumor Cerebrae Headache

Pseudotumor cerebrae. Very special type of headache. Women more than men. Young adults more than older adults. African-Americans more than white. Obese patients. Visual complaints because of the papilledema, a swelling of the brain that includes the retinal apparatus. Remember that the eyes are part of the brain, and the brain’s pressure is up, so there will be increased pressure on the optic nerve leading to increased pressure in the eye which shows up as papilledema on fundiscopic exam (the ophthalmoscope exam, when the doc looks deep into your eyes). The patient feels papilledema if they are conscious as altered vision. Treatment of choice, to relieve the increased intracranial pressure: lumbar puncture.

Clever segue here. Common cause of headaches, a recent lumbar puncture. Headache occurs a few days later. It is exacerbated by sitting up. Laying back down makes a headache improve.

High Altitude Headaches

High altitude headaches. Going from sea level to a high altitude produces this. The important distinction here is to make and not to miss something called high-altitude cerebral edema. Treatment: descend back to a low altitude; and steroids for the edema.

Carbon Monoxide Poisoning Headaches

Carbon monoxide poisoning. Classic presentation is multiple family members presenting with a headache at the same time. So be keenly aware of a brother and sister showing up giddy, lethargic, complaining of a headache, all of which started together.


So these are general principles. The big carry home, if it’s not a high risk headache, you might avoid imaging.

But even if it is not a high-risk headache, it’s often better just to get the imaging if anyone is confused about the possibilities of something more dangerous. If your physician is trying to get all clever as to whether or not to get a CT or an MRI, or a CTA even, I might change physicians. There should be no delay on finding out what a non-high-risk headache is or is not if anyone is concerned about anything that might be life-threatening. Imaging is the answer key and should not be delayed for purposes of academia and cleverness. And when it comes to a CT even, it’s safe.