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Neurology Committee Senior Deputy Editor Robert G. Kaniecki, MD, Section Editor Patrick C. Alguire, MD, FACP Director, The Headache Center American College of Physicians Chief, Headache Division Philadelphia, Pennsylvania Assistant Director, Neurology Residency Training Program Director, Headache Fellowship Program Deputy Editor Associate Professor of Neurology Janet A. Jokela, MD, MPH, FACP, FIDSA University of Pittsburgh School of Medicine Professor and Head, Department of Medicine Pittsburgh, Pennsylvania Acting Regional Dean Amar B. Bhatt, MD, FAES University of Minois College of Medicine Assistant Professor, Epilepsy Section Urbana, Illinois Rush University Medical Center Chicago, Illinois Neurology Reviewers Daniel Harrison, MD Thomas P Bleck. MD, MCCM, FACP Associate Professor of Neurology James Dorman, MD, FAAN, FACP Director, Division of Multiple Sclerosis and Lisa N. Miura, MD, FACP Neuroimmunology Garey Noritz, MD, FAAP, FACP University of Maryland Center for Multiple Sclerosis Ravi Patel, MD Treatment and Research Prasad N. Policherla, MD, FAAN University of Maryland School of Medicine Ali Seifi, MD, FACP, FNCS, FCCM Baltimore, Maryland Amit M. Shelat, DO, FACP, FAAN Houman Homayoun, MD Jorawar Singh, MD, FACP, CHCQM-Phyadv

Committee Senior Deputy Editor Robert G. Kaniecki, MD, Section Editor Patrick C. Alguire, MD, FACP Director, The Headache Center American College of Physicians Chief, Headache Division Philadelphia, Pennsylvania Assistant Director, Neurology Residency Training Program Director, Headache Fellowship Program Deputy Editor Associate Professor of Neurology Janet A. Jokela, MD, MPH, FACP, FIDSA University of Pittsburgh School of Medicine Professor and Head, Department of Medicine Pittsburgh, Pennsylvania Acting Regional Dean Amar B. Bhatt, MD, FAES University of Minois College of Medicine Assistant Professor, Epilepsy Section Urbana, Illinois Rush University Medical Center Chicago, Illinois Neurology Reviewers Daniel Harrison, MD Thomas P Bleck. MD, MCCM, FACP Associate Professor of Neurology James Dorman, MD, FAAN, FACP Director, Division of Multiple Sclerosis and Lisa N. Miura, MD, FACP Neuroimmunology Garey Noritz, MD, FAAP, FACP University of Maryland Center for Multiple Sclerosis Ravi Patel, MD Treatment and Research Prasad N. Policherla, MD, FAAN University of Maryland School of Medicine Ali Seifi, MD, FACP, FNCS, FCCM Baltimore, Maryland Amit M. Shelat, DO, FACP, FAAN Houman Homayoun, MD Jorawar Singh, MD, FACP, CHCQM-Phyadv Assistant Professor of Neurology University of Pittsburgh School of Medicine Hospital Medicine Neurology Reviewers Pittsburgh, Pennsylvania Alan J. Hunter, MD, FACP Marissa Natelson Love. MD P. Dileep Kumar, MD, MBA, FACP, FAAPL CPE Associate Professor, Department of Neurology Christopher Migliore, MD, MS Division of Memory Disorders and Behavioral Neurology University of Alabama at Birmingham Neurology ACP Editorial Staff Birmingham, Alabama Elise Paxson, Medical Editor, Assessment and Education Joshua Z. Willey, MD, MS Programs Associate Professor of Neurology Margaret Wells, Ed.M., Director, Assessment and Education Program Director, Vascular Neurology Fellowship Programs Medical Director, New York Presbyterian Hospital Columbia Becky Krumm, Senior Managing Editor, Assessment and Comprehensive Stroke Center Education Programs Columbia University Vagelos College of Physicians and Surgeons New York, New York ACP Principal Staff Davoren Chick, MD, FACP Senior Vice President. Medical Education Editor-in-Chief Tabassum Salam, MD, MBA, FACP Davoren Chick. MD, FACP Vice President, Medical Education Senior Vice President, Medical Education American College of Physicians Patrick C. Alguire, MD, FACP Philadelphia, Pennsylvania MKSAP Senior Deputy Editor

Neurology Headache and Facial Pain Additional testing is determined by differential diagnostic considerations and may include erythrocyte sedimentation Approach to the Patient rate determination, C-reactive protein measurement, lumbar puncture, serum chemistries, or toxicology screens. There is with Headache no indication for electroencephalography in the assessment of Formal classification of headache disorders identifies three headache disorders. headache subtypes: primary headaches, secondary head- aches, and painful cranial neuralgias. Primary headaches, or those in which the symptoms are due to a specific head- TABLE 1. Secondary Headache and Associated Syndromes ache disorder, are more commonly seen in practice and are Posttraumatic headache defined by clinical criteria. Primary headache disorders Head injury include migraine, tension-type headache, cluster head- Whiplash injury ache, and the other trigeminal autonomic cephalalgias (TACs). Secondary headaches result from another underly- Headache attributed to cranial or cervical vascular disorder ing process and are defined by that causative disease pro- Ischemic stroke or transient ischemic attack

Approach to the Patient rate determination, C-reactive protein measurement, lumbar puncture, serum chemistries, or toxicology screens. There is with Headache no indication for electroencephalography in the assessment of Formal classification of headache disorders identifies three headache disorders. headache subtypes: primary headaches, secondary head- aches, and painful cranial neuralgias. Primary headaches, or those in which the symptoms are due to a specific head- TABLE 1. Secondary Headache and Associated Syndromes ache disorder, are more commonly seen in practice and are Posttraumatic headache defined by clinical criteria. Primary headache disorders Head injury include migraine, tension-type headache, cluster head- Whiplash injury ache, and the other trigeminal autonomic cephalalgias (TACs). Secondary headaches result from another underly- Headache attributed to cranial or cervical vascular disorder ing process and are defined by that causative disease pro- Ischemic stroke or transient ischemic attack cess (Table 1); these headaches may be associated with Intracranial hemorrhage significant morbidity and mortality and require early iden- Unruptured vascular malformation or aneurysm tification. Patients with serious secondary headaches typi- Intracranial or extracranial arteritis cally have acute or subacute symptoms and a headache Arterial dissection pattern that is progressive or unstable; suspicion of a sec- ondary headache is heightened in the presence of the fol- Cerebral venous sinus thrombosis lowing clinical “red flags”: Headache attributed to nonvascular intracranial disorders

cess (Table 1); these headaches may be associated with Intracranial hemorrhage significant morbidity and mortality and require early iden- Unruptured vascular malformation or aneurysm tification. Patients with serious secondary headaches typi- Intracranial or extracranial arteritis cally have acute or subacute symptoms and a headache Arterial dissection pattern that is progressive or unstable; suspicion of a sec- ondary headache is heightened in the presence of the fol- Cerebral venous sinus thrombosis lowing clinical “red flags”: Headache attributed to nonvascular intracranial disorders ¢ Worst headache Intracranial hypotension or hypertension e Abrupt-onset or thunderclap attack Brain neoplasia Noninfectious inflammatory disorders (neurosarcoidosis) e Progression or fundamental change in headache pattern Chiari malformation ¢ Neurologic deficit Headache attributed to substance use or withdrawal e New headache in persons older than 50 years Medication adverse event (nitrates) ¢ New headache in patients with malignancy, coagulopathy, Alcohol immunosuppression, or pregnancy Caffeine withdrawal ¢ Headache triggered by position, exertion, sexual activity, or Valsalva maneuver Medication overuse headache Headache attributed to infection A detailed headache history is the most valuable clini- cal assessment tool in the evaluation of headaches. Intracranial infection (meningitis, encephalitis, brain abscess)

Noninfectious inflammatory disorders (neurosarcoidosis) e Progression or fundamental change in headache pattern Chiari malformation ¢ Neurologic deficit Headache attributed to substance use or withdrawal e New headache in persons older than 50 years Medication adverse event (nitrates) ¢ New headache in patients with malignancy, coagulopathy, Alcohol immunosuppression, or pregnancy Caffeine withdrawal ¢ Headache triggered by position, exertion, sexual activity, or Valsalva maneuver Medication overuse headache Headache attributed to infection A detailed headache history is the most valuable clini- cal assessment tool in the evaluation of headaches. Intracranial infection (meningitis, encephalitis, brain abscess) Neurologic examination with funduscopic testing is essen- Extracranial infection (systemic bacterial infection, viral tial, and brain imaging is the most important diagnostic syndrome) study. Brain MRI with contrast is indicated for some of the Headache attributed to disorder of homeostasis uncommon primary syndromes (such as TACs). For thun- Hypertensive crisis, dialysis, hypoxia, hypercapnia, derclap headache, CT imaging of the head without contrast hypothyroidism is most appropriate. For a new headache with optic disc Headache attributed to disorder of the neck, eyes, ears, nose, edema, or headaches with clinical “red flags,” brain MRI sinuses, teeth, or mouth with or without contrast or CT without contrast is usually Headache attributed to a psychiatric disorder

is most appropriate. For a new headache with optic disc Headache attributed to disorder of the neck, eyes, ears, nose, edema, or headaches with clinical “red flags,” brain MRI sinuses, teeth, or mouth with or without contrast or CT without contrast is usually Headache attributed to a psychiatric disorder appropriate. For chronic headaches with new or progressive Adapted with permission of SAGE Publications LTD., London, Los Angeles, New features, brain MRI with contrast is appropriate. Stable Delhi, Singapore and Washington DC, from Headache Classification Committee of the International Headache Society (IHS). The International Classification of headaches meeting criteria for most primary headaches Headache Disorders, 3rd edition. |CHD-3 Cephalalgia 2018;38:64. [PMID: 23771276] | doi: 10.1177/0333102417738202. usually do not require imaging. i