Headaches represent one of the commonest somatic complaints seen in clinical practice. Between 1.7% and 2.5% of annual emergency department (ED) visits are by patients with a chief complaint of headache.<sup>24 Dhopesh V., Nwar R., Herring C. A retrospective study of emergency department patients with complaint of headache Headache 1979 ;  19 : 37-42  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 99 Thomas S.H., Stone C.K. Emergency department treatment of migraine, tension and mixed-type headache J Emerg Med 1994 ;  12 : 657-664  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> It has been estimated that as many as 70% to 90% of the general population will suffer from at least one headache during any given year, with 5% seeking medical attention.<sup>83 Robinson R.G. Pain relief for headaches: Is self-medication a problem? Can Fam Physician 1993 ;  39 : 867-872

Cliccare qui per andare alla sezione Riferimenti, 90 Silberstein S.D., Silberstein M.M. New concepts in the pathogenesis of migraine headache Pain Management 1990 ;  3 : 297-302

Cliccare qui per andare alla sezione Riferimenti, 94 Spence J. Migraine and other causes of headache Ann Emerg Med 1996 ;  27 : 448-450  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Economic impact, in terms of lost work days and decreased productivity secondary to headaches, has been estimated at $5.6 to $7.2 billion annually.<sup>75 Osterhaus J.T., Autterman D.L., Plachetka J.R. Healthcare resource and lost labor costs of migraine headache in the United States Pharmacoeconomics 1992 ;  2 : 67-76  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>

The differential diagnosis of headache is one of the longest in medicine (Table 1). The International Headache Society has classified headache into 13 major categories, with 129 subcategories.<sup>45 Headache Classification Committee of the International Headache Society Classification and diagnostic criteria for headache disorders, cranial neuralgia, and facial pain Cephalgia 1988 ;  8 (Suppl 7) : 1

Cliccare qui per andare alla sezione Riferimenti</sup> Primary headache syndromes, including tension and migraine headache, represent the majority of headaches presenting both to primary care physicians and to EDs.<sup>24 Dhopesh V., Nwar R., Herring C. A retrospective study of emergency department patients with complaint of headache Headache 1979 ;  19 : 37-42  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> A study by Edmeads et al demonstrated that 14% of migraine sufferers and 8% of patients with tension headache will present to the ED for treatment at some time during their lives.<sup>30 Ellis M.E., Ralston S. The ESR in the diagnosis and management of the polymyalgia rheumatica/giant cell arteritis syndrome Ann Rheum Dis 1983 ;  42 : 168-170  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>

Secondary headaches may be defined as headaches occurring as part of the symptom complex of another condition. Some of these, such as temporomandibular joint headache, are benign, whereas others are associated with significant morbidity and mortality. Secondary headaches occur in as many as 10% of patients seen in the emergency department.<sup>76 Perkins T., Ondo W. When to worry about headache: Head pain as a clue to intracranial disease Postgrad Med 1995 ;  98 : 197-208

Cliccare qui per andare alla sezione Riferimenti</sup> Dhopesh et al performed a retrospective study of all patients presenting to a large urban ED with the complaint of headache over the period of 1 year.<sup>24 Dhopesh V., Nwar R., Herring C. A retrospective study of emergency department patients with complaint of headache Headache 1979 ;  19 : 37-42  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> The five commonest discharge categories were infection (other than intracranial), tension headache, vascular headache, blood pressure–related headache, and post-traumatic headache. Of the 872 patients, 11 (1.2%) had serious underlying pathology, with 6 of the 11 (55%) being intracranial hemorrhage (ICH). Distinguishing this group with serious underlying pathology from the headache population at large lies at the heart of the difficult challenge that headaches pose to emergency physicians. By definition, the patient presenting to the emergency department represents an a priori high-risk group. The true onus is on the emergency physician not to determine the underlying cause of the headache, but more importantly to exclude clinically significant underlying pathology. Fifty-two (6%) of patients in the study by Dhopesh et al. were discharged from the ED with no diagnosis.<sup>24 Dhopesh V., Nwar R., Herring C. A retrospective study of emergency department patients with complaint of headache Headache 1979 ;  19 : 37-42  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> In reviews of malpractice claims filed against emergency physicians in the state of Massachusetts, misdiagnosed subarachnoid hemorrhage and meningitis were consistently in the high-risk category, accounting for as many as 5% and 2% of all closed cases respectively.<sup>57 Karcz A., Holbrook J., Burke M.C. , e al. Massachusetts emergency medicine closed malpractice claims: 1988–1990 Ann Emerg Med 1993 ;  22 : 553-559  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 58 Karcz A., Korn R., Burke M.C. , e al. Malpractice claims against emergency physicians in Massachusetts: 1975–1993 Am J Emerg Med 1996 ;  14 : 341-345  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>

Numerous chapters and articles have been written concerning the most frequent ominous causes of secondary headache (Table 2).<sup>4 Anderson D.C., Kozak A.J. Meningitis, encephalitis and brain abscess Emergency Medicine: A Comprehensive Study Guide New York: McGraw-Hill (1996).  1049-1055

Cliccare qui per andare alla sezione Riferimenti, 20 Coutin I.B., Glass S.F. Recognizing uncommon headache syndromes Am Fam Physician 1996 ;  54 : 2247-2252

Cliccare qui per andare alla sezione Riferimenti, 25 Dodick D. Headache as a symptom of ominous disease: What are the warning signals? Postgrad Med 1997 ;  101 : 46-64

Cliccare qui per andare alla sezione Riferimenti, 36 Fontanarosa P. Subarachnoid hemorrhage The Clinical Practice of Emergency Medicine Philadelphia: Lippincott-Raven (1996).  865-869

Cliccare qui per andare alla sezione Riferimenti, 38 Gallagher E.J. Headache The Clinical Practice of Emergency Medicine Philadelphia: Lippincott-Raven (1996).  856-865

Cliccare qui per andare alla sezione Riferimenti, 47 Hoffman G.L. Headache and facial pain Emergency Medicine: A Comprehensive Study Guide New York: McGraw-Hill (1996).  1008-1014

Cliccare qui per andare alla sezione Riferimenti, 61 Kothari R.U., Barsan W. Management of stroke Emergency Medicine: A Comprehensive Study Guide New York: McGraw-Hill (1996).  1014-1021

Cliccare qui per andare alla sezione Riferimenti, 81 Raskin N.H. Short-lived head pains Neurol Clin 1997 ;  15 : 143-152  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 85 Roberge R.J. Meningitis and encephalitis The Clinical Practice of Emergency Medicine Philadelphia: Lippincott-Raven (1996).  789-793

Cliccare qui per andare alla sezione Riferimenti, 87 Scott P.A., Barsan W.G. Cerebrovascular disease The Clinical Practice of Emergency Medicine Philadelphia: Lippincott-Raven (1996).  869-879

Cliccare qui per andare alla sezione Riferimenti</sup> Current recommendations mandate a thorough diagnostic evaluation of all patients who present with a “first-or-worst” headache, a progressive subacuteheadache, headache associated with abnormal signs or symptoms (e.g., fever, meningismus, nausea, papilledema, focal neurologic deficits), headaches in HIV-positive patients, or new-onset headaches in patients over the age of 50 years.<sup>32 Evans R.W. Diagnostic testing for the evaluation of headaches Neurol Clin 1996 ;  14 : 1-26  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> The emergency physician must be attuned to the diagnoses of cerebrovascular disease, subarachnoid hemorrhage (SAH), and bacterial meningitis. The purpose of this article is to aid the clinician by expanding the differential diagnosis of headaches associated with significant morbidity and mortality (Table 2). To this end, seven less common yet equally significant causes of headache are reviewed, with emphasis placed on clinical features and diagnostic studies of choice.