Always perform a fundoscopic exam and screen for secondary headaches. If any red flags are present, you should obtain, at minimum, an MRI brain with and without contrast +/- MRA and MRV. If it is a thunderclap HA, obtain a STAT CTH and CTA head/neck and inquire about RCVS precipitants. There is a low threshold for an LP (particularly if pt presents >6h from symptom onset as sensitivity of CTH begins to decrease for SAH). If getting LP, check opening pressure, cell count, protein, glucose at minimum. If the pt is pregnant, obtain STAT MRI, MRV, MRA head/neck all without contrast to rule out venous thrombosis, PRES, pituitary apoplexia, dissection, and RCVS.
Is there a HA History? Previous HA diagnosis
Characterize Current Headaches How long ago did the HA begin?
Lateralization
Location
Quality
Severity out of 10
Frequency
HA Duration
Associated Symptoms
Alleviating Factors
Medications Tried AEDs
Antidepressants
Tricyclics
SNRIs
SSRIs
NE and DA reuptake inhibitor
Other Antidepressant
Antihypertensives
Beta-blockers
Calcium Channel Blockers
ACE-i
ARBs
OTCs
Duration and frequency of abortive agents used: _______ Tylenol/NSAIDS >15 d/mo and triptans >10 d/mo increase risk of medication overuse HA Nonpharmacologic Measures tried
Screen for Secondary HAs Systemic conditions (Increased risk for secondary HA)
Associated symptoms that increase risk for secondary HA
Exacerbating Factors
Substance Use/Exposure
Medical History
Prior Workup
Information about Thunderclap HA Ddx Subarachnoid Hemorrhage
CTH/CTA will be positive in: 90-95% on first day 70% by day 3 50% at 1 week LP will show xanthrochromia by: 12 hours Peaks at 3-4 days Resolves within 2 weeks
RCVS
Women, 40yo, migrainers Recurrent thunderclap HAs over weeks CTA/MRA/DCA shows "string and beads" appearance Complications: ischemic or hemorrhagic strokes
Carotid dissection
Obtain CTA/MRA Associated with recent minor trauma (MVA, chiropractor) Can have Horner syndrome or pulsitile tinnitus
Cerebral Venous Sinus Thrombosis (CVST)
2-5% of thunderclap headaches Usually more gradual headache Women > men Associated with OCPs, pregnancy and the puerperium, malignancy, infection, head injury and mechanical precipitants