Headache Evaluation Framework
Headaches are universal, with a lifetime prevalence of over 90%. While severely painful, the vast majority are primary headaches (tension or migraine) lacking underlying pathology. This guide outlines how to differentiate common causes and identify the rare "red flags" that require emergency imaging.
SNOOP Red Flags (Emergency Triage)
If you experience any of the following, seek immediate emergency medical care:
- Systemic symptoms (fever, chills, unexpected weight loss)
- Neurological deficits (weakness, numbness, vision loss, speech difficulty)
- Onset is sudden ("Thunderclap" headache, max intensity in seconds)
- Older onset (New headache beginning after age 50)
- Pattern change (Progressive worsening, changes with posture/position)
Base Rates: What is statistically likely?
When presenting to a primary care physician with a headache lacking red flags, the diagnostic breakdown is overwhelmingly weighted toward primary headaches:
- Tension-type headaches: ~69% of cases
- Migraines: ~16% of cases
- Idiopathic stabbing/other primary: ~2% of cases
- Secondary (caused by other condition): Less than 10%, often minor infections (sinus, viral).
Differentiating Primary Headaches
| Feature | Tension-Type | Migraine |
|---|---|---|
| Pain Quality | Pressing, tightening (non-pulsating) | Pulsating, throbbing |
| Location | Bilateral (band-like around head) | Unilateral (usually one-sided) |
| Intensity | Mild to moderate | Moderate to severe (disabling) |
| Aggravation | Not worsened by routine activity | Worsened by physical activity |
| Associated Symptoms | None (no nausea, rare sensitivity to light/sound) | Nausea/vomiting, photophobia, phonophobia |
Medication Overuse Headache (MOH)
A frequently missed diagnosis is the Medication Overuse Headache (rebound headache). Paradoxically, taking pain relievers too often causes chronic daily headaches.
The Thresholds: Using simple analgesics (Ibuprofen, Acetaminophen) more than 15 days per month, or combination analgesics/triptans more than 10 days per month, for over 3 months.
Questions for Your Doctor
To make the most of a 15-minute appointment, bring answers to these specific questions:
- How many days per month am I completely headache-free?
- Exactly how many days a week am I taking acute pain medication?
- On a scale of 1-10, how disabling is the pain, and does it prevent me from working/functioning?
Ask the physician: "Based on my headache diary, do I qualify for preventative medication rather than just acute treatment?"