First Episode of Recurrent Headache

It’s technically impossible to “officially” diagnose migraine, cluster, or tension headache during the first-ever episode.  The latter isn’t as problematic, because there are no red flags.  But a new migraine or cluster headache, possibly severe, with nausea and/or eye symptoms, might easily suggest an entity in the DO NOT MISS column.

Careful delineation of symptom chronology is the key.  Migraines build to a maximal intensity over 30-60 minutes, not 1-2 like an SAH.  An episode commonly lasts 8-72 hours.  Cluster headaches begin abruptly, but last less than 3 hours, remit, and recur.  There’s no fever, neuro exam is normal, and the patient doesn’t look ill.  Patients who actually look sick probably need a same-day E.D. work-up.

See posting Recurrent Headaches for discussion of migraine & cluster.