What are the initial steps and labs for a patient presenting with a throbbing headache?

Initial Steps and Labs for Throbbing Headache Evaluation

The initial evaluation of a patient with throbbing headache should focus on identifying "red flags" that suggest secondary headache requiring urgent attention, followed by a systematic assessment to determine the headache type, with neuroimaging and laboratory testing reserved for cases with concerning features. 1

Red Flag Assessment

• Assess for warning signs that suggest a secondary headache requiring urgent attention:
  • Recent onset headache that is worsened by Valsalva maneuver or cough 1, 2
  • Headache that awakens patient from sleep 1, 2
  • Fever or signs of infection 1
  • Sudden onset of the "worst headache of life" (thunderclap headache) 3, 4
  • New headache in patients over 50 years of age 2, 4
  • Focal neurologic signs or symptoms 3, 4
  • Headache following trauma 3
  • Headache that worsens with exercise 3
  • Neck stiffness or meningeal signs 3, 4
  • Personality changes or altered mental status 3, 4
  • Immunocompromised state 3
  • Papilledema on examination 3, 4

Diagnostic History

• Obtain key diagnostic information to determine headache type:
  • Location (unilateral vs. bilateral) 1
  • Character (pulsating/throbbing vs. pressing/tightening) 5, 6
  • Intensity (mild, moderate, severe) 5, 6
  • Duration (hours, days) 5, 1
  • Frequency (episodic vs. chronic) 5
  • Associated symptoms (nausea, vomiting, photophobia, phonophobia) 5, 6
  • Presence of aura symptoms 5, 6
  • Aggravating and relieving factors 5
  • Family history of headache disorders 5, 6

Physical Examination

• Perform a complete neurological examination to identify abnormalities that may indicate secondary headache 6, 4
• Check vital signs, particularly for fever or hypertension 1, 4
• Examine the head and neck for tenderness, masses, or signs of trauma 4
• Assess for papilledema and other fundoscopic abnormalities 3, 4
• Evaluate for meningeal signs (neck stiffness, Kernig's sign, Brudzinski's sign) 3, 4

Laboratory Testing

• For patients with red flags, consider the following laboratory tests:
  • Complete blood count (to assess for infection or inflammation) 4, 7
  • Basic metabolic panel (to evaluate for electrolyte abnormalities) 4, 7
  • Erythrocyte sedimentation rate and C-reactive protein (if temporal arteritis is suspected, particularly in patients >50 years) 4, 7
  • Toxicology screening (if substance use is suspected) 7

Neuroimaging

• Neuroimaging is warranted in the following situations:

  • Unexplained abnormal findings on neurologic examination 1
  • New onset headache in patients over 50 years 1, 2
  • Atypical features that don't fit established primary headache patterns 1
  • Sudden onset severe headache (thunderclap) 3, 4
  • Headache with focal neurologic deficits 3, 4
  • Headache with signs of increased intracranial pressure 3, 4

• Type of neuroimaging:

  • Non-contrast head CT is recommended if intracranial hemorrhage is suspected 1, 4
  • MRI brain is preferred for most other concerning headache presentations 1, 4
  • Lumbar puncture should be considered if subarachnoid hemorrhage is suspected and CT is negative 4

Headache Diary

• Provide the patient with a headache diary to track:
  • Frequency and pattern of headaches 1, 6
  • Associated symptoms 1, 6
  • Medication use and response 1, 6
  • Potential triggers 1, 6

Diagnostic Criteria for Common Primary Headaches

• Migraine without aura requires at least five attacks with:

  • Headache lasting 4-72 hours 5, 6
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity 5, 6
  • At least one of: nausea/vomiting, photophobia and phonophobia 5, 6

• Chronic migraine requires:

  • Headache on ≥15 days/month for >3 months 5
  • Migraine features on ≥8 days/month 5

• Tension-type headache typically presents with:

  • Bilateral location 8
  • Pressing/tightening quality 8
  • Mild to moderate intensity 8
  • No significant autonomic features 8

• Cluster headache presents with:

  • Severe unilateral pain lasting 15-180 minutes 8
  • Ipsilateral autonomic symptoms 8
  • Frequency of 1-8 attacks daily during cluster periods 8