7B. Secondary headaches

Page created on June 3, 2021. Last updated on April 6, 2022 at 12:48


Secondary headaches are those headaches which occur as a feature of an underlying disease. The list of disorders which can cause secondary headaches is endless. It’s important to know the red flags of headache which may suggest a severe pathology, so that proper evaluation can be performed in patients presenting with these red flags.


  • Mass-occupying lesions
    • Epidural haemorrhage
    • Subdural haemorrhage
    • Subarachnoid haemorrhage
    • Intracerebral haemorrhage
    • Tumour
    • Brain abscess
  • Other CNS pathology
    • Meningitis/encephalitis
    • Cerebral venous sinus thrombosis
    • Ischaemic stroke/TIA
    • Dissection of carotid/vertebral artery
    • Post head trauma
  • Extracranial disorders
    • Infections near to the CNS (sinusitis, etc.)
    • Systemic infection
    • Hypertensive emergency
    • Acute glaucoma
    • Temporal arteritis and other vasculitides
    • Substance abuse (alcohol, etc.)
    • Substance withdrawal (caffeine, etc.)
    • Medication side effect
      • Nitrates
      • Analgesic overuse – overuse of analgesics can cause headache

Red flags/signs

  • Non-specific symptoms like fever – rule out metastasis, infection
  • Neurological symptoms – rule out stroke, CNS lesion, encephalitis
  • Age > 50 at onset – rule out temporal arteritis, severe hypertension, tumour
  • Hyperacute onset (esp. thunderclap) – rule out haemorrhagic stroke
  • Papilloedema or precipitated by Valsalva or exertion – rule out raised ICP
  • Positional – rule out intracranial hypotension
  • Progressive worsening or significant change in symptom pattern of a known headache – rule out all secondary causes

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