i. Acute new-onset headache

History excludes previous similar attacks

Perform a full neurological examination in search for the cause. If examination fails to provide clues then a CAT scan or MRI should be ordered.

Causes of new onset headache and clinical features

1. Meningitis: Acute, severe headache with stiff neck and fever suggests meningitis.

2. Intracranial hemorrhage: Acute, severe headache with stiff neck but without fever suggests subarachnoid hemorrhage.

3. Brain tumor: Intermittent deep, dull aching of moderate intensity, which may worsen with exertion or change in position and may be associated with nausea and vomiting.

4. Temporal arteritis: Temporal (giant cell) arteritis is an inflammatory disorder of arteries that frequently involves the extracranial carotid circulation.

5. Glaucoma

6. Other causes:

  • Systemic Illness There is hardly any illness that is never manifested by headache; however, some illnesses are frequently associated with headache. These include infectious mononucleosis, systemic lupus erythematosus, chronic pulmonary failure with hypercapnia (early morning headaches), Hashimoto's thyroiditis, inflammatory bowel disease, many of the illnesses associated with HIV, and the acute blood pressure elevations that occur in pheochromocytoma and in malignant hypertension. Hypertension per se is a very uncommon cause of headache; diastolic pressures of at least 120 mmHg are requisite for hypertension to cause headache. Some drugs and drug-withdrawal states, e.g., oral contraceptives, ovulation-promoting medications, and glucocorticoid withdrawal, are also associated with headache in some individuals. Nitrates may be associated with headache that is usually controlled with acetaminophen (tylenol).
  • Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Headache, clinically resembling that of brain tumor, is a common presenting symptom of pseudotumor cerebri, a disorder of raised intracranial pressure probably resulting from impaired cerebrospinal fluid CSF absorption by the arachnoid villi.
  • Cough headache are characterized by transient, severe head pain upon coughing, bending, lifting, sneezing, or stooping. The incidence of serious intracranial structural anomalies causing this condition is about 25%; the Chiari malformation is a common cause. Thus, MRI is indicated for most patients with cough headache.
  • Lumbar Puncture Headache following lumbar puncture. Head pain is dramatically positional; it begins when the patient sits or stands upright; there is relief upon reclining or with abdominal compression.
  • Postconcussion headaches.
  • Post-coital headache occurs mainly in males (4:1).

ii. Chronic recurrent headache

History shows recurrent attacks

Causes of recurrent headache

1. Tension type headache

2. Migraine

3. Cluster headache

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