The first stage of diagnosis is a thorough medical and neurological examination, to exclude the possibility of secondary headache. In diagnosing secondary headaches, the patient’s history is all important. A careful physical examination will be done to check for clues to possible headache causes and also to check the nervous system. The exam can help determine whether further testing is needed.
Any abnormal results in the physical exam may suggest a possible underlying cause of headache. Abnormal results may include:
- Fever, which may indicate an infection such as sinusitis. Headache with fever, stiff neck, nausea and vomiting may indicate meningitis.
- Headache that began suddenly in a person who has not had headaches before, or a dramatic change in an established headache pattern.
- Headache that follows any form of physical exertion, such as exercise, sexual activity, coughing or bending. These types of headaches are usually not caused by a serious problem, but occasionally they can be related to an aneurysm (ballooning of the wall of one of the blood vessels in the brain).
- Abnormal speech, eye movements, walking, co-ordination or reflexes.
- Abnormal eye exam, which indicates there may be increased pressure inside the skull.
- High blood pressure.
- Other findings, such as arthritis, which may suggest autoimmune disease.
- Onset of headaches after the age of about 55 could indicate a condition called temporal arteritis, which may, amongst other things, cause blindness if not treated early.
Imaging tests, such as MRI, MRA or CT scan, may be needed if your doctor suspects there is an underlying organic cause such as an aneurysm or brain tumour (although these are fortunately quite rare). Your doctor may also order an imaging test if your headaches continue to get worse despite conventional treatment.
People with primary headache, such as tension-type, migraine or cluster headache will usually have a normal physical examination.
Once the neurological examination has been done (and in the vast majority of headache sufferers this examination reveals no abnormality), the next step is to ascertain from which anatomical structures the pain originates.
The ideal way to do this is to employ what is called a “multidisciplinary” approach. There are so many different structures in the head and neck, all of which can be involved in the headache process, that no single clinician or specialist can have all the knowledge necessary to make a comprehensive assessment and diagnosis. For this reason, the expertise of different specialists who would normally treat headache patients in isolation, should be combined and integrated into a single more comprehensive body of knowledge. This enables the team to provide a co-ordinated treatment plan, so that all the contributing factors are addressed.
Keeping a headache diary may help to identify triggers, and is also useful for evaluating the effectiveness of treatment.