Disorders presenting with headache as the sole symptom

Headache is one of the commonest medical complaints, and ranks high among the reasons why people consult neurologists and general practitioners. Most headache patients are, however, managed suboptimally; and indeed, many neurologists find outpatient headache management one of the least engaging parts of their job. Headache may present as part of a symptom complex or it may present alone. When it is part of a complex, the total presentation of the patient serves as pointer to any underlying disease. When it is the sole symptom however, identifying the specific cause can be more difficult. Even though the diagnosis and management of most cases of headache probably do not require sophisticated neurological skills or investigations, failure to recognise an underlying disorder or an attitude of total neglect can be fatal. In this paper, we briefly review some of the disorders reported to have presented with headache as the sole symptom with the aim of drawing attention to the need for proper attitude to every headache complaint even when it initially appears to be trivial. Two groups of headache are recognised - primary and secondary. More than 90% of headaches seen in practice are of the primary type, which includes migraine, tension and cluster headaches. Secondary headache results from a wide range of disorders which may be intracranial, extracranial or systemic. Intracranial causes of headache include tumours, haematomas, infections, idiopathic intracranial hypertension and vascular disorders. Some of the more common extracranial and systemic causes are shown in Tables 1 and 2 respectively. Recognition of these conditions requires a standardised diagnostic approach to history and examination, wherein the patient's history alerts the physician while the physical examination provides support for the diagnosis.