A pain in the head

Not sure why I always post about pain on Fridays, but here I go again. We’ve had some discussions about headaches in Red Clinic lately (and I don’t mean the VA formulary), and I thought it would be useful to review some diagnostic strategies.


Remember the mnemonic:  POUND Pulsatile One day Unilateral Nausea Daily activity (Interferes with daily activity) These are intense, debilitating headaches, often with  nausea and photo/phonophobia. Patients will “take to the bed” to get over them. May have an aura: visual or sensory disturbances that are fully reversible.

Tension Headache

Milder in intensity, bilateral, throbbing in quality. May have muscle tenderness over the scalp or neck. Patients usually can stay at work, continue activities with these headaches.

Cluster Headaches

Rare Patients  have episodes of daily headache, intense, usually unilateral and associated with autonomic symptoms.  They will have symptom free periods between “clusters” for months or even years.

Medication Rebound Headache

Common Daily headache associated with regular use of almost any medicine for headache treatment.  Most common with opiates, butabital containing meds (Midrin), or caffeine containing meds (fioricet or excedrin). Intermediate risk of triptans. Lowest risk with NSAIDs.


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