Updated 10 February 2016

Diagnosing headaches

The first stage of diagnosis of a headache is a thorough medical and neurological examination in order to exclude the possibility of secondary headache.

Primary headaches are the most common kind of headache and occur for no obvious reason. Secondary headaches, however, are the result of other conditions.

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, but a careful physical examination is even more important 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, among 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. 

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 coordinated 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.

Read more: 

Causes of headaches  

Preventing headaches 

Treating headaches

Reviewed by Dr Elliot Shevel, BDS, Dip MFOS, MB, BCh, Maxillo-facial and Oral Surgeon and Medical Director, The Headache Clinic, Johannesburg and Cape Town, February 2015.

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


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Dr Elliot Shevel is a South African migraine surgery pioneer and the founder and medical director of The Headache Clinic in Johannesburg, Durban and Cape Town, South Africa. The Headache Clinic is a multidisciplinary practice dedicated to the diagnosis and treatment of Primary Headaches and Migraines. Dr Shevel is also the main author of all scientific publications generated by his team. He recently won a high level science debate in which he was able to prove that the current migraine diagnosis and classification is not based on data. Tertiary Education - Dr Shevel holds both Dental and Medical degrees, and practises as a specialist Maxillo-facial and Oral Surgeon. Follow the Headache Clinic on Twitter@HeadacheClinic.

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