Diagnosis of Headaches
A headache is one of the most common reasons patients seek help from primary care providers. In both the office and emergency room, migraine headaches cause more physician visits than all other types of headaches. Migraine headaches are a common disorder and affect nearly one in every four households in the United States, 18% of women and 6% of men suffer from migraine. There are roughly 21 million American women with migraine and 7 million men with migraine headaches. Migraine headaches occur most frequently in both men and women between the ages of 25 and 55.
Estimates of the prevalence of tension-type headache vary widely with ranges from 28% to 63% in men and 34% to 86% in women between the ages of 18 and 65.
Headache is a symptom with many causes. The symptoms of headache may occur as part of an acute complex, such as occurs with migraine, or may be part of an evolving disorder, such as occurs with a brain tumor.
Headache disorders are divided into:
- Primary Headache Disorders – migraine, tension-type headaches (TTH), cluster headaches.
- Secondary Headache Disorders – brain tumors, aneurysms, cerebrovascular accidents. See table 1.
It is very important to separate the primary and secondary headache disorders. When seeing a headache patient for the first time a complete history and neurological examination will usually help differentiate the type of headache disorder.
Several questions need to be asked in order to identify the headache type, these questions are noted in Table 2.
There are certain comfort features in the history of someone who suffers from migraine headaches which aid in the diagnosis of migraine. These are outlined in Table 3. Patients with secondary headache disorders will often have features in the history that should alert the doctor and suggest the need for further evaluation. These are noted in Table 4.
Neurological and physical examinations are important. Abnormal findings which would warrant further evaluation to rule out structural lesions are listed in Table 5. Table 6 lists abnormal findings associated with the general medical exam. In general, neuroimaging studies are not necessary to diagnose the majority of headache disorders. They are often ordered by primary care providers to support their diagnosis of a primary headache disorder and to rule out a secondary headache disorder. The guidelines for the use of neuroimaging studies such as CAT or MRI scans of the brain in headache are listed in Table 7. When diagnosing a secondary headache disorder, the history, the physical and the neurological examinations are all important.
Many patients present with acute headaches. If head trauma, blood, or subarachnoid hemorrhage is suspected, a CAT scan of the brain should be done immediately. All other disorders of the brain are usually diagnosed with an MRI. If trying to differentiate a posterior fossa lesion from other conditions, an MRI of the brain should be done rather than a CAT scan, because of artifacts associated with CAT scans of the posterior fossa.
Prior to 1988, the classification of headaches was poor. In 1988, the International Headache Society (IHS) instituted its classification system and this has become the standard for both diagnosis and clinical research. This classification divides headaches into primary headache disorders and secondary headache disorders.5 The primary headache disorders include migraine, tension-type headaches, cluster headaches, and miscellaneous conditions. The IHS criteria labels these 1 to 4 (Table 8).
The IHS criteria have useful, but limited utility. They were designed for clinical research, not clinical practice. The criteria often do not recognize important variations of migraine and other headache disorders. For instance, the diagnosis of migraine and the localization of the pain does not always agree with the IHS definitions. Many patients with migraine have neck pain as a presenting symptom and these cases would fall outside of the guidelines of the IHS classification.
Famous people with migraine include: Terrell Davis, the running back for the Broncos who had a migraine attack during Super Bowl XXXII, and had to take Migranal® nasal spray on the sideline; Kareem Abdul Jabbar, the Los Angeles Lakers basketball star, has had migraine headaches all his life. Famous individuals with migraine in the past include Julius Caesar (100-44 b.c.), Napoleon Bonaparte (1769 to 1821), and Sigmund Freud, the father of psychoanalysis (1856 to 1939). Famous women with migraine include Michelle Akers, who played on the U.S. soccer team and Cindy of the Brady Bunch.
Differential Diagnosis of Headache
PRIMARY HEADACHE DISORDERS
- Migraine Headache
- Tension Type Headache
- Episodic tension type
- Chronic tension type (Chronic Daily Headache (CDH), Chronic Migraine (CM), Rebound Headache)
- Cluster Headache
- Miscellaneous Headaches Not Associated With Structural Lesions
- Cold Stimulus headache
- Headache associated with sexual activity
- Benign cough headache
- Benign exertional headache
SECONDARY HEADACHE DISORDERS
- Brain tumor, abscess
- Subarachnoid hemorrhage, aneurysm, arteriovenous malformation
- Intracerebral hemorrhage
- Head trauma, subdural or epidural hematoma
- Meningitis / encephalitis
- Cerebrovascular disease
- Inflammation (temporal or giant cell arteritis)
- Cranial neuralgias: trigeminal neuralgia, occipital neuralgia
- Increased intracranial pressure (pseudotumor cerebri, aquaductal stenosis)
- Low pressure headaches (post lumbar puncture, spontaneous, trauma induced)
QUESTIONS TO AID IN HEADACHE DIAGNOSIS
- How long have you been suffering with headaches?
- What age were you when the headaches began?
- Do you know when a headache is coming on – do you have an aura – flashing lights, numbness of one side of the body?
- How often do you get a headache?
- Are there any aggravating or precipitation factors?
- Family history of headaches?
- How long do the headaches last?
- Where is the pain located?
- Describe the pain.
- On a scale of 1 – 5 how strong is the pain?
- Are there any other symptoms?
- Previous medications tried, both prescription and over-the- counter.
- Previous diagnostic studies.
- Impact of the headaches – How does it disrupt your life? Are the headaches disabling? Do you miss work, school, play, social activities? Does it keep you from doing things you would normally do?
- Current treatment, if any.
COMFORT FEATURES FOR DIAGNOSING MIGRAINE HEADACHES
- Family history of migraine (present in the majority of patients)
- Headache pain which changes locations
- Menstrual association
- Stable headache pattern
- Otherwise healthy individual
- Prodromes and/or auras
- Fulfills IHS criteria
- Resolution with sleep
HEADACHE WARNING SIGNS SUGGESTING FURTHER EVALUATION
- Onset of headache after age 50
- Onset of a new or different type of headache
- Change in a headache pattern
- The “Worst” headache ever experienced, sudden “apoplectic” event
- The first headache ever experienced
- The onset of a subacute headache that progressively worsens over time
- The abrupt onset of headache with exertion, sexual activity, coughing, or sneezing
- A headache not fitting a defined pattern and not responding to aggressive treatment
- An abnormal neurological examination
ABNORMAL NEUROLOGICAL EXAMINATION
- Headache associated with any of the following neurological findings suggest continued investigation.
- Drowsiness, confusion, memory impairment
- Weakness, ataxia, loss of coordination
- Numbness and/or tingling in extremities
- Sensory loss associated with headache
- Asymmetry of pupillary response, deep tendon reflexes, or Babinski response
- Signs of meningeal irritation (neck pain, back pain)
- Progressive visual or neurological changes
- Other evidence to suggest an underlying neurological disorder, such as persistent tinnitus, loss of smell, loss of sensation over the face, dysphagia, etc.
ABNORMAL MEDICAL EVALUATION
- Stiff neck
- Weight loss
- Tender, poorly pulsatile temporal arteries
- Chronic cough, lymphadenopathy, recurrent nasal drainage/discharge, or other evidence to suggest a systemic illness
GUIDELINES FOR USE OF CAT OR MRI IN HEADACHES
- The use of neuroimaging procedures may be indicated when any of the following is present.
- An abnormal neurological examination, such as decreased alertness, focal neurological signs or nuchal rigidity
- New onset of headaches after age 50
- The first headache or the “worst” headache ever experienced
- An increasing frequency and/or severity of the headaches
- A change in the headache pattern
- An abrupt onset of the headache with exertion, coitus, coughing or sneezing
- A headache not fitting a defined pattern and not responding to aggressive treatment
INTERNATIONAL HEADACHE SOCIETY (IHS)
The Classification of Headache Disorders
A. Primary headache disorders
1.1 Migraine without aura
1.2 Migraine with aura
1.3 Ophthalmoplegic migraine
1.4 Retinal migraine
1.5 Childhood periodic syndromes that may be precursors to or associated with migraine
1.6 Complications of migraine, such as status migrainosis and migrainous infarction.
1.7 Migrainous disorder not fulfilling above criteria
- Tension type headache
2.1 Episodic tension type headache
2.2 Chronic tension type headache
2.3 Headache of the tension type not fulfilling above criteria
- Cluster headache and chronic paroxysmal hemicrania
3.1 Cluster headache
3.1.1. Cluster headache periodicity undetermined
3.1.2. Episodic cluster headache
3.1.3. Chronic cluster headache
3.2 Chronic paroxysmal hemicrania
3.3 Cluster headache-like disorder not fulfilling above criteria
- Miscellaneous headaches unassociated with structural lesion
4.1 Idiopathic stabbing headache
4.2 External compression headache
4.3 Cold stimulus headache
4.4 Benign cough headache
4.5 Benign exertional headache
4.6 Headache associated with sexual activity