Differential Diagnosis of Headache

Subarachnoid 
Hemorrhage
Meningitis Temporal Arteritis  Hypertensive Migraine Cluster Muscle Contraction
Onset Acute Acute or chronic Acute or chronic Acute or Chronic Acute Acute Chronic
Location Global Global Localized Localized Unilateral Unilateral Global unilateral 
Associated Symptoms N, V, LOC, meningismus, focal neurologic symptoms N, V, fever, photophobia miningismus, focal symptoms, seizures Weight loss, PMR, fever, decreased vision, jaw claudication N, V, focal neurologic symptoms N, V, photophobia, phonophobia Rhinorrhea, lacrimation of side Multisomatic complaints
Pain 
characteristics
worst ever severe throbbing severe throbbing over affected area  Throbbing Throbbing Sharp, stabbing Ache
Duration Brief Brief Prolonged Brief Prolonged 30 min-2 hrs Daily
Prior history (-) (-) (-) (+) (+) (+) (+)
Diagnostic tests CT 80-90% LP (+), CBC WSR (+) CT scan to rule out bleeding - - -
Physical Examination Focal signs, decreased LOC, meningismus Miningismus, decreased LOC, irritability, rash Tender temporal arteries, myalgias, fever Papilledema, decreased venous pulsations, decreased LOC, 
cerebrovascular changes
N, V, photophobia, phonophobia Unilateral rhinorrhea, lacrimation, partial Homer’s syndrome (-)
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Types of Headache in the Emergency Department 

Final Diagnosis Percentage
Infection—Other than intracranial  39.3
Tension headache  19.3
Miscellaneous  14.9
Post-traumatic  9.3
Hypertension related  4.8
Vascular (Migraine type)  4.5
No diagnosis  6.0
Subarachnoid hemorrhage  0.9
Meningitis  0.6
Migraine and tension  0.5 
Source: Michael Gerardi, MD, FAAP, FACEP
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