Version June 2024
| Diagnosis | History | Suggestive clinical findings |
| Subarachnoid hemorrhage | Thunderclap onset; severe pain at onset; transient loss of consciousness; severe neck pain; diplopia | Meningismus; nausea and vomiting |
| Reversible cerebral vasoconstriction syndromes (RCVS) | Thunderclap headaches of short duration that recur over days to weeks; may have recurrent trigger (eg, exertion, emotional stress, cough) | Neurologic deficits from underlying stroke or edema may develop |
| Cervical artery dissection | Recent head or neck trauma, even minor; prominent neck pain; new acute dizziness; tinnitus | Nystagmus; Horner syndrome (ptosis, miosis); cervical bruit; cranial neuropathy; stroke or TIA |
| Cerebral vein and dural sinus thrombosis | Risk factors for venous thromboembolism: highly variable presentation; headache; seizure | Neurologic deficits not consistent with arterial lesion; seizure; papilledema; encephalopathy |
| Hypertensive encephalopathy/reversible posterior leukoencephalopathy syndrome | Seizures and visual symptoms with headaches of insidious onset; nausea and vomiting | Severe hypertension (relative to patient's baseline); papilledema and retinal hemorrhage; encephalopathy; hematuria and proteinuria |
| Meningitis/encephalitis NOTE: Patients with Lyme meningitis often do not have severe findings | Ill appearing; fever (often >38°C); neck pain or stiffness; confusion or lethargy (may be sole finding in older adults) | Fever; meningismus; altered mental status; seizure; CN palsies; petechiae or purpura |
| Brain abscess | Headache (onset may be acute or gradual); recent history of bacteremia or head/neck infection; neck stiffness; fever (possibly) | Fever (often absent); papilledema; focal or cranial neurologic deficits (develop days to weeks after headache onset); depressed mental status |
| Brain tumor | History of cancer; headache exacerbated by cough, Valsalva, and maneuvers that increase ICP; headache can be sudden onset if bleeding into a tumor; nausea and vomiting | Papilledema; seizure; depressed mental status; neurologic deficits (weakness, sensation, aphasia, visual abnormalities) |
| Intracranial, extra-axial hematoma (subdural, epidural) | History of head trauma (even minor); SDH can present weeks after trauma; use of anticoagulant medications | Coma; progressive decline in mental status; hematoma in posterior fossa can present with: vomiting, anisocoria, dysphagia, CN palsies, nuchal rigidity, ataxia |
| Intraparenchymal hemorrhage (IPH) | Headache usually sudden in onset; use of anticoagulant medications | Findings on neurologic examination depend on site of hemorrhage (examination may be unremarkable) |
| Colloid cyst of third ventricle | Positional headache that may resolve upon lying flat; confusion; symptoms may be intermittent | Altered mental status with headache |
| Idiopathic intracranial hypertension | Overweight or obese female of childbearing age; intermittent visual symptoms (eg, decline in vision; flashes, double vision) | Papilledema; sixth cranial nerve palsy; visual deficit (eg, field cut; may be transient); tinnitus; other CN palsies |
| Spontaneous intracranial hypotension | Severe headache upon standing (often within 15 minutes) that resolves with lying flat; Valsalva exacerbates headache; tinnitus; neck pain; nausea and vomiting | Neurologic examination often normal; wide range of possible findings |
| Acute narrow-angle glaucoma | Eye pain; red or tearing eye; decreased vision; nausea and vomiting | Red, injected conjunctiva; "steamy" edematous cornea; fixed, mid-dilated pupil (4 to 6 mm); firm globe; elevated IOP (often >30 mmHg) |
| Giant cell arteritis | Patient 50 years or older with headache, abrupt onset visual disturbances (transient monocular vision loss), and possibly jaw claudication, fever | Palpable or nodular temporal arteries; wide range of possible symptoms and signs; fever; elevated ESR and/or CRP |
| Carbon monoxide toxicity | History of CO exposure; others at same site affected (eg, worksite or abode); headache resolves or declines when away from CO source | Findings vary with severity of exposure; severe exposure can produce coma, seizures, myocardial ischemia; moderate or mild exposure causes malaise, nausea, dizziness; may see cherry red macula on funduscopy |
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