What is the appropriate workup for a young male presenting with a throbbing headache?

Workup for Throbbing Headache in Young Male

MRI brain without contrast is the preferred initial neuroimaging study for a young male with throbbing headache when imaging is indicated, with contrast added only if the initial study is abnormal. 1

Initial Assessment

When evaluating a young male with throbbing headache, focus on:

• Red flag symptoms requiring immediate imaging:

  • Sudden onset/thunderclap headache (could indicate subarachnoid hemorrhage)
  • Headache with vomiting or neurological deficits
  • Headache increasing in frequency, duration, or severity
  • Headache waking patient from sleep
  • Headache triggered by Valsalva maneuver
  • Occipital headache (rare in young patients)

• Associated symptoms suggesting secondary causes:

  • Fever, neck stiffness (meningitis)
  • Visual changes (increased intracranial pressure)
  • Focal neurological deficits (stroke, tumor)
  • Altered mental status

Imaging Decision Algorithm

1. Primary vs. Secondary Headache

   • Primary headaches (migraine, tension) rarely require imaging
   • Secondary headaches (those caused by another condition) typically require imaging

2. When to Image

   • Image immediately if any red flags are present
   • Image if headache pattern changes dramatically (could indicate aneurysm) 2
   • Image if headache is refractory to appropriate treatment

3. Imaging Modality Selection

   • First choice: MRI brain without contrast 1

     • Add contrast if initial study shows abnormality
     • Include SWI/GRE sequences if trauma history exists

   • CT head without contrast (when MRI unavailable or in emergency setting) 1, 3

     • Faster acquisition
     • Better for detecting acute blood products
     • Add contrast if brain tumor suspected and MRI not possible

   • Additional imaging based on suspected etiology:

     • Thunderclap headache: CT head without contrast + lumbar puncture if CT negative 4
     • Suspected arterial dissection: MRA/CTA head and neck
     • Suspected venous sinus thrombosis: MRV (preferred) or CTV

Special Considerations

• Thunderclap Headache: Requires immediate evaluation with CT and lumbar puncture if CT is negative, as 11.3% may have subarachnoid hemorrhage 4

• Recurrent/Chronic Headaches: Consider underlying psychiatric conditions (depression, anxiety) which are present in up to 71% of adolescents with chronic headaches 5

• Neuroimaging Yield: Only about 1% of children with headaches have relevant findings on MRI that explain their headaches 6

• Common Pitfalls:

  • Failing to image when headache characteristics change significantly
  • Overreliance on normal neuroimaging when symptoms persist (consider other diagnoses)
  • Missing medication overuse headache in patients with chronic headaches
  • Attributing all headaches to primary causes without adequate workup for secondary causes

After Imaging

If neuroimaging is negative but headaches persist:

• Consider referral to headache specialist, especially for frequent or disabling headaches 6
• Evaluate for medication overuse headache
• Consider non-pharmacological approaches alongside medication

Remember that while most throbbing headaches in young males represent primary headaches (migraines), thorough evaluation for secondary causes is essential when red flags are present, as missing conditions like aneurysm, arteriovenous malformation, or tumor can lead to significant morbidity and mortality.