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Probability diagnosis


  • respiratory infection


  • tension-type headache

  • combination headache

  • migraine

  • transformed migraine

Serious disorders not to be missed


  • subarachnoid haemorrhage

  • intracranial haemorrhage

  • carotid or vertebral artery dissection

  • temporal arteritis

  • cerebral venous thrombosis


  • cerebral tumour

  • pituitary tumour


  • meningitis (esp. fungal)

  • encephalitis

  • intracranial abscess

Haematoma: extradural/subdural


Benign intracranial hypertension

Pitfalls (often missed)

Cervical spondylosis/dysfunction

Dental disorders

Refractive errors of eye


Ophthalmic herpes zoster (pre-eruption)

Exertional headache


Post-traumatic headache (e.g. post-concussion)

Post-spinal procedure (e.g. epidural, lumbar puncture)

Sleep apnoea


  • Paget disease

  • post-sexual intercourse

  • cluster headache

  • Cushing syndrome

  • Conn syndrome

  • Addison disease

  • dysautonomic cephalgia

Masquerades checklist



Drugs (see list)


Thyroid disorder and other endocrine (as above)

Spinal dysfunction (cerviogenic)


Is the patient trying to tell me something?

Quite likely if there is an underlying psychogenic disorder.

Key history

A full description of the pain including a pain analysis should be obtained, especially associated symptoms. It is useful to get the patient to prepare a diary with a grid plotting the relative pain intensity with time of day. Family history, psychosocial history and drug history.

Key examination

  • Use the basic tools of trade: thermometer, sphygmomanometer, pen torch, diagnostic set with ophthalmoscope and stethoscope

  • Inspect the head, temporal arteries and eyes

  • Areas to palpate include the temporal arteries, the facial and neck muscles, the cervical spine and sinusitis, teeth and TMJs

  • Look for signs of meningeal irritation and papilloedema

  • A mental state examination is advisable

  • Perform a basic neurological examination

Key investigations


  • FBE


  • selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).

Diagnostic tips

  • Hypertension is an uncommon cause of headache.

  • ‘Combination headaches’, which can last for days, have a mix of components such as tension, depression, vascular headache and drug dependence.

  • A patient >55 years presenting with unaccustomed headache probably has an organic cause.

  • Drugs that may cause headache: alcohol, analgesics (rebound), caffeine, antihypertensives (several), COCP, corticosteroids, NSAIDs (esp. indomethacin), vasodilators esp. nitrates, sildenafil.

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