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Headache Differential Diagnosis & Documentation

Blog_HeadacheDocumentationPearls_HeadacheGeriatricWomanDocExam_260x200p.jpg[3 MIN READ]

Headache is a common reason for a visit to practitioners in primary care, urgent care, and emergency medicine. Patients with the chief complaint of non-traumatic headache comprise 3% of all emergency department visits.

The vast majority of these headaches will have a benign etiology such as tension or migraine. Unpredictably interspersed among these benign presentations are patients with a serious cause of headache such as hemorrhage or CNS infection.

Malpractice cases involving headaches frequently involve the missed diagnosis of subarachnoid hemorrhage (SAH). The reasons the diagnosis of SAH is missed include the following:

  1. It can be a difficult diagnosis.
  2. Headache is a common and principal complaint, and SAH occurs in only 1% of headache patients.
  3. The classic presentation of SAH is not common.
  4. Practitioners are not aggressive in ruling out SAH.
  5. The chart does not adequately reflect the practitioner’s reasoning process.

The foundation of high-quality, defensible care consists of a systematic approach to the differential diagnosis for headache supported by compulsive documentation.

The essence of liability reduction in the care of patients with headache is to construct a medical record that provides a thorough, clear and logical explanation for the examiner’s thoughts and actions. Below are a few key items to address in the chart documentation.

History of Present Illness Questions

  • Location: Where it started and where is it now
  • Onset: Sudden or instant, gradual
  • Severity: Worst ever?
  • Quality: Is this a new type of headache never felt before?
  • Associated Signs & Symptoms: Nausea, vomiting, neurologic symptoms, seizure, syncope, change in mental status, neck pain or stiffness, sinus or dental pain, visual changes, fever, photophobia, hearing loss, nasal discharge
  • Context: History and pattern of prior headache,  migraines, prodrome, aura
  • Modifying Factors: What helps or hurts (analgesics, lights)?

website_author_syzek1-e1446040915762.jpgRisk Factors

  • SAH Risk Factors: First-degree relative with an aneurysm, connective tissue disease
  • Hemorrhage Risk Factors: Hypertension, anticoagulants
  • CNS Lesion Risk Factors (mass or hemorrhage): Prior neurosurgical procedures, congenital disease, immunocompromised, recurrent infections, malignancy, coagulopathy, substance abuse, pregnancy
  • Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Risk Factors: Obesity, young women, anemia, thyroid disease, pregnancy, antibiotics, oral contraceptives

Physical Exam

  • Mental Status: Orientation, alertness, responsiveness, behavior, fluctuations in level of consciousness
  • Head and Face: Scalp tenderness, sinus, TMJ, jaw, temporal arteries
  • Eyes: Periorbital edema, corneal clouding, injection, globe pressure, visual acuity, pain with eye movements, fundi
  • Oral Cavity: Dental sensitivity
  • Neck: Supple, stiff, rigidity or meningeal signs, bruits
  • Neurological: Cranial nerves, motor, sensory, gait, cerebellar (coordination), speech, visual fields, reflexes

Medical Decision-Making

  • If a CT is done for the reason of ruling out SAH and is negative, either perform a lumbar puncture (unless contraindicated) or document the patient’s informed refusal.
  • Address the results of all tests ordered.
  • Document a differential diagnosis and discuss your reasoning regarding the likelihood (or not) of serious causes for headache, including SAH, intracranial hemorrhage, mass lesion, CNS infection, meningitis, temporal arteritis, glaucoma, hypertensive crisis, pseudotumor cerebri, migraine, tension, cluster, pre-eclampsia, sinusitis.


  • For admitted patients, record who was consulted and when.
  • For discharged patients, include time-specific (i.e., within 24 hours) and person-specific (i.e., PCP, neurologist) follow-up in the discharge instructions.
  • Provide clear instructions that include specific reasons to return to the ED (i.e., persistence or worsening of pain, change in character, fever, stiff neck, vomiting, confusion, altered consciousness, seizure, focal weakness, ataxia, visual loss, speech deficit).


Most headache malpractice suits occur with patients who are sent home rather than admitted. The most important tool for providing good care and reducing liability is clear communication with patients and their families. Tell them what you are thinking and why, what diagnostic tests will be performed and their limitations, who to see next and when, and the reasons to return to the ED. Remind them that THEY ARE WELCOME TO RETURN ANY TIME THEY PERCEIVE THEIR CONDITION IS WORSE.



We cover subarachnoid hemorrhage extensively in the following courses:




Categories: Diagnostic Error, Emergency Medicine, Patient Safety, Urgent Care


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