see also:

• headache

• is there a Horner's syndrome present?
  • consider internal carotid artery dissection which needs emergency Ix
  • if male and occurring at night, consider cluster headache
• is there ant/lateral neck pain, new tinnitus or monocular blindness?
  • consider internal carotid artery dissection which needs emergency Ix
• is there occipital pain +/- new tinnitus, chiropractic manipulation or local trauma?
  • consider vertebral artery dissection which needs emergency Ix
• persistent pain in one dermatome suggests:
  • acute herpes zoster - watch for development of vesicles
  • post-herpetic neuralgia
• brief severe lancinating pain of part of the front half of head lasting seconds triggered by light touch suggests typical trigeminal neuralgia
  • usually in those > 50yrs (if presents in younger adults or affecting ophthalmic division, consider multiple sclerosis (MS), post. fossa tumour, cerebral aneurysm, meningioma, acoustic neuroma, TB, sarcoidosis, etc)
  • nb. constant aching, burning, stabbing pain may be type 2 atypical trigeminal neuralgia or atypical facial pain
• pain in throat radiating to ear precipitated by cough, yawn or swallowing cold fluids suggests glossopharyngeal neuralgia
• pain in TMJ radiating to ear or temple suggests temporomandibular joint dysfunction
• is there tenderness of temporal artery, recent visual changes, or age > 50yrs?
  • consider temporal arteritis and do urgent ESR or CRP and if significantly raised, arrange for biopsy and start steroids ASAP
• if last 15-180 min in men occurring at night and associated with Horner syndrome, unilateral blocked nose, etc, consider cluster headache
• if piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears (some also have pain in scalp, forehead, and behind the eyes), then consider occipital neuralgia
• if lasts more than 3 hours and is associated with nausea, photophobia or phonophobia, then it is most likely a migraine
• if there is lateral high cervical tenderness then suspect cervicogenic headache
  • this may be caused by C2 facet joint degeneration and C2 nerve root irritation causing unilateral retro-orbital / temporal headaches and may precipitate migraine

• cluster headache
• migraine
  • migraineurs often have retro-orbital migraines
  • ophthalmoplegic migraine:
    • v. rare, mainly children
    • periorbital pain and diplopia secondary to cranial neuropathies following a migraine attack
• acute glaucoma - an ophthalmic emergency - associated with red eye, dilated pupil, impaired vision
• Tolosa-Hunt Syndrome:
  • rare, is associated with acute transient ophthalmoplegia +/- impaired vision
  • due to inflammation within the cavernous sinus or superior orbital fissure
• cavernous sinus thrombosis
  • rare, may be associated with fever, ptosis and diplopia