What is the appropriate initial evaluation and work‑up for a 30‑year‑old patient presenting with new‑onset headache and generalized body aches?

Initial Evaluation of a 30-Year-Old with Headache and Body Aches

Begin with a focused history to identify red-flag features that mandate immediate neuroimaging, then perform a targeted neurological examination; in the absence of red flags and with a normal exam, this presentation most likely represents a primary headache disorder (migraine or tension-type) or a viral syndrome, and routine neuroimaging is not indicated. 1, 2

Step 1: Screen for Red-Flag Features Requiring Urgent Evaluation

Ask specifically about the following danger signals that indicate possible secondary headache requiring immediate workup:

• Thunderclap onset (maximum intensity within seconds to minutes) suggests subarachnoid hemorrhage 1
• "Worst headache of life" or abrupt severe onset indicates possible vascular pathology 1
• Headache awakening from sleep may signal increased intracranial pressure 1
• Worsening with Valsalva, coughing, or exertion suggests elevated intracranial pressure 1, 3
• Recent head trauma raises concern for intracranial injury 1
• Fever points toward meningitis or other infection 1
• Progressive worsening over time could indicate space-occupying lesion 1

If any red flag is present, proceed immediately to neuroimaging (see Step 4). 1

Step 2: Perform Targeted Neurological and Physical Examination

The examination takes less than 3 minutes and should focus on detecting signs of secondary headache: 4

• Focal neurological deficits (weakness, sensory loss, coordination problems) have a likelihood ratio of 5.3 for serious pathology and mandate immediate imaging 1
• Neck stiffness (resistance to passive flexion) indicates meningitis or subarachnoid hemorrhage 1
• Papilledema on fundoscopy signals raised intracranial pressure 1
• Cranial nerve abnormalities (palsies, Horner's syndrome) suggest secondary causes 1
• Coordination testing (finger-to-nose, heel-to-shin, gait) to detect cerebellar pathology 1
• Altered consciousness or impaired memory indicates serious secondary causes 1

If the neurological examination is completely normal, the probability of serious intracranial pathology drops to 0.2%, comparable to asymptomatic volunteers (0.4%). 1

Step 3: Characterize the Headache Pattern

When red flags are absent and exam is normal, distinguish primary headache types:

Migraine Features

• At least two of: unilateral location, throbbing quality, moderate-to-severe intensity, worsening with routine activity 5, 2
• At least one of: nausea/vomiting OR both photophobia and phonophobia 5, 2
• May have aura (visual distortions, scotomas) or prodromal symptoms (food cravings, heightened sensory perception, mood changes) 5, 2

Tension-Type Headache Features

• At least two of: pressing/tightening quality, mild-to-moderate intensity, bilateral location, no worsening with routine activity 5, 2
• No nausea/vomiting AND no simultaneous photophobia plus phonophobia (one may be present) 5, 2

Consider Viral Syndrome

• Body aches (myalgias) accompanying headache in a 30-year-old without red flags commonly represents viral illness
• Look for other systemic symptoms: malaise, low-grade fever, upper respiratory symptoms

Step 4: Imaging Decisions (Only When Indicated)

Routine neuroimaging is NOT indicated for patients under 50 with normal neurological examination and no red-flag features; the yield is only 0.9% (95% CI 0.5-1.4%). 2

When Imaging IS Required (Red Flags Present):

• MRI brain without contrast is preferred for most secondary headache evaluation due to superior resolution 1
• Non-contrast CT head is indicated only for:
  • Thunderclap headache (rule out subarachnoid hemorrhage) 1
  • Recent trauma 1
  • When MRI is contraindicated or unavailable 1

If Thunderclap Headache and CT Negative:

• Perform lumbar puncture >6 hours from symptom onset to evaluate for xanthochromia (sensitivity 100% at 12 hours through 2 weeks) 1, 6

Step 5: Laboratory Testing (Selective Use Only)

Laboratory tests are NOT routinely indicated for typical primary headache in a 30-year-old. 5

Consider targeted labs only if:

• Fever present: CBC, blood cultures to evaluate for infection 1
• Systemic symptoms suggest metabolic cause: basic metabolic panel (glucose, sodium abnormalities can cause headache) 7

Critical Pitfalls to Avoid

• Do not order neuroimaging solely for patient reassurance when exam is normal and no red flags exist; this exposes patients to unnecessary radiation, cost, and risk of incidental findings leading to further unwarranted testing 1
• Do not assume viral syndrome if any red flag is present; thunderclap headache or focal deficits require immediate imaging regardless of concurrent body aches 1
• Do not start daily analgesics before establishing diagnosis, as this can lead to medication-overuse headache 2, 7
• Do not rely solely on imaging without considering the complete clinical picture; history and examination drive the diagnostic approach 1

Management When No Red Flags Present

• For acute migraine: NSAIDs or acetaminophen first-line; triptans if diagnosis confirmed and no contraindications 5, 7
• For tension-type headache: NSAIDs or acetaminophen 5
• For suspected viral syndrome: supportive care, NSAIDs for symptom relief
• Advise return immediately if red-flag symptoms develop 1