Diagnosing a headache

The headache history is, by far, the most important tool a doctor has to evaluate headache. Keep a headache diary.

In diagnosing 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.

People with tension-type, migraine or cluster headaches usually will have a normal physical exam.

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)
• 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

The history and physical exam are all that is needed to diagnose benign headaches, including tension-type and migraine headaches. Additional tests are only needed to help diagnose other conditions which may cause symptoms like those of tension-type and migraine headaches.

Imaging tests, such as MRI 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 quite rare). Your doctor may order an imaging test if:

• Your headaches continue to get worse despite conventional treatment.
• The part of the physical exam that checks your nervous system is not normal. Most people with tension-type and migraine headaches have normal results in their nervous system exam.

Imaging tests that may be used in these cases include:

• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA)

Any person over the age of 55 with a recent onset headaches should be tested for temporal arteritis by means of a blood test (ESR).

Reviewed by Dr Andrew Rose-Innes, MD, Department of Neurology, Yale University School of Medicine, New Haven.