Headaches have many causes, ranging from benign to life threatening, and always warrant thorough assessment. Neurologic causes such as subarachnoid hemorrhage, meningitis, or mass lesions are especially ominous. The careful clinician pays close attention to the history and a detailed neurologic examination.
Always assess the severity of the headache and its location, duration, and any associated symptoms such as double vision, visual changes, weakness, or loss of sensation. Does the headache get worse with coughing, sneezing, or sudden head movements, which can alter intracranial pressure dynamics? Is there fever, stiff neck, or a parameningeal focus like ear, sinus, or throat infection that may signal meningitis?
An atypical presentation of the patient's usual migraine may be suspicious for stroke, especially in women using hormonal contraceptives.
Always look for unusual headache warning signs, such as sudden onset "like a thunderclap," onset after age 50 years, and associated symptoms such as fever and stiff neck. Examine for papilledema and focal neurologic signs.
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