Evaluation of Headache - CLINICAL MEDICINE - MedIND
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JIACM 2005; 6(1): 17-22
CLINICAL MEDICINE
Evaluation of Headache
Amal Kumar Bhattacharya*
Abstract
While episodic tension-type headache is common in population-based studies, migraine is the most common diagnosis in patients
presenting to primary care physicians with headache. The appropriate evaluation of headache should be as per the following:
Rule-out serious underlying pathology, and look for other secondary causes of headache.
Determine the type of primary headache using the patient’s history as the primary diagnostic tool. There may be overlap in
symptoms, particularly between migraine and tension-type headache, and between migraine and some secondary causes of
headache (such as sinus disease). Use of an instrument, such as the brief headache screen, appears to be helpful in identifying
patients with migraine in particular.
An imaging study is not necessary in the vast majority of patients presenting with headache. Nevertheless, imaging (usually
CT scan) is warranted in the patients outlined above.
Key word: Headache.
Introduction cumbersome for day-to-day use. The IHS criteria are most
useful for grouping patients for scientific purposes, such
Headache is among the most common medical
as clinical trials and epidemiologic studies.
complaints. The overall prevalence of migraine is
estimated to be 12 to 16 percent. Population-based As many as 90 per cent of all benign headache disorders
studies are hardly found and reliable for other chronic fall under a few categories, including migraine, tension-
headache syndromes, but tension-type headache seems type, and cluster headache. While a population-based
to be more prevalent than migraine. Both migraine and study found that the one-year prevalence of episodic
tension-type headaches affect women more often than tension-type headache was 38 per cent1, most of these
men, while cluster headache (excluding chronic people do not present to physicians for care2,3.
paroxysmal hemicrania) is predominantly a disorder of
men. Cluster headache typically leads to significant disability,
and most of these patients do come for medical attention.
Like many other chronic disorders, migraine not only However, cluster headache remains an uncommon
affects the quality of life of the sufferer, but also causes an diagnosis in a primary care setting, because of its overall
economic burden on the society. low prevalence in the general population (around 0.1 per
cent)4.
Epidemiology and classification of headache
Clinicians can easily become familiar with the most
Many controversies exist in the literature regarding the common headache disorders and how to differentiate
nomenclature and classification of headache. The between them (Table I). It is not necessary to follow the
international headache society (IHS) developed and detailed classification and diagnostic criteria proposed by
published a new classification and diagnostic criteria in the IHS, although there are certain important points that
1988. This system gives operational diagnostic criteria for should be kept in mind whenever describing, managing,
headaches, cranial neuralgias, and facial pain syndromes. or discussing patients with headache:
The IHS classification also details which clinical features
must be present, and in what combination, to establish a It is not appropriate to use the term vascular
precise diagnosis. However, this classification system is headache to describe migraine and cluster
* Associate Professor, Department of Medicine, Government Medical College, Surat - 395 002, Gujarat.headache, nor is it correct to use the term muscle History
contraction headache, to describe common
A systematic case history is the single most important
headache types that are without typical
factor in establishing a headache diagnosis and
migrainous or other autonomic features.
determining the future work-up and treatment plan. A
The term tension-type headache should be used to thorough history also helps focus on the physical
describe all headache syndromes in which muscle examination and thus prevent unnecessary investigations
contraction is considered to be the most significant and imaging studies.
factor in the pathogenesis of the headache.
A systematic case history should include the following:
Headache due to vascular abnormalities, aneurysm, Age at onset
or arteriovenous malformation should be described Presence or absence of aura and prodrome
separately from migraine or cluster headache, since
Frequency, intensity, and duration of attack
these are different diseases pathophysiologically, and
Time and mode of onset
the management strategies are also different.
Quality, site, and radiation of pain
The use of the term “psychogenic headache” should
Associated symptoms and abnormalities
be discouraged since it tends to be confusing to
Family history of migraine
patients and wrongly suggests that organic processes
are not involved. Precipitating and relieving factors
Effect of activity on pain
A number of other disorders may cause headache. In
the Brazilian primary care study, 39 per cent of patients Relationship with food/alcohol
presenting with headache had a headache that was Response to any previous treatment
due to a systemic disorder (most commonly fever, Any recent change in weight or vision
acute hypertension, and sinusitis), and 5 per cent had Association with recent trauma
a headache that was due to a neurologic disorder
Any recent changes in sleep, exercise, or diet
(most commonly post-traumatic headache, headache
secondary to cervical spine disease, and expansive State of general health
intracranial processes) 2. Physicians who evaluate Change in work or lifestyle
patients with headache should be alert to signs that Possible association with environmental factors
suggest a serious underlying disorder. Change in method of birth control (women)
Patients frequently attribute headache to eye strain, and Effects of menstrual cycle (women)
the IHS recognises headaches associated with refractive
The most common headache syndromes frequently
errors (HARE). However, an observational study suggested
present with characteristic symptoms shown Table I.
that headache are only rarely due to refractive error alone5.
However, there may be considerable symptom overlap;
Nevertheless, correcting vision may improve symptoms
one population-based survey found that only less than
in some of these patients.
one-half of patients who complained of headache
meeting the IHS criteria for migraine were properly
Principles of the headache evaluation
diagnosed6. Migraine symptoms may also overlap with
Evaluating a patient with pain of new onset headache can other causes of headache. As an example, a significant
be challenging. It requires a systematic approach based number of patients with migraine may have nasal
upon an understanding of the common headache symptoms that suggest sinus disease7. In addition, a study
syndromes. Making a correct diagnosis is the first and of primary care patients with recurrent sinus headache
foremost step in the proper management of any patient found that 90 per cent experienced attacks that met the
with headache. IHS criteria for migraine8.
18 Journal, Indian Academy of Clinical Medicine Vol. 6, No. 1 January-March, 2005Table I : Characteristics of common headache syndromes.
Symptom Migraine headache Tension headache Cluster headache
Location Unilateral in 60 to 70 per cent, Bilateral Always unilateral, usually
bi-frontal or global in 30 begins around the eye or
per cent temple
Characteristics Gradual in onset, crescendo Pressure or tightness Pain begins quickly, reaches
pattern; pulsating; moderate which waxes and a crescendo within minutes;
or severe intensity; aggravated wanes pain is deep, continuous,
by routine physical activity excruciating, and explosive
in quality
Patient’s attitude Patient prefers to rest in a Patient may remain active Patient remains active
dark, quiet room or may need to rest
Duration 4 to 72 hours Variable 30 minutes to 3 hours
Associated Nausea, vomiting, None lpsilateral lacrimation and
symptoms photophobia, phonophobia; redness of the eye; stuffy
may have aura (usually nose; rhinorrhoea; pallor;
visual, but can involve sweating; Horner’s syndrome;
other senses or cause focal neurologic symptoms
speech or motor deficits) rare; sensitivity to alcohol
Diagnostic instruments: Given the pitfalls described patients (1.7 percent) with migraine were not identified
above, a number of diagnostic instruments have been by disabling headache. Thus, virtually any patient with
proposed, primarily to assist in the diagnosis of migraine, severe episodic headache can be considered to have
the most common primary headache syndrome in migraine.
patients presenting to primary care physicians. A simple,
Questions 2 and 3 can be helpful for identifying patients
and recently validated instrument, the brief headache
with medication overuse, e.g., patients who use
screen, appears to be well suited to identify migraine in
symptomatic medications more than three days per week
the primary care setting. Different versions of the brief
and/or who have daily headaches. Question 4 is
headache screen have been promoted, including a range
particularly helpful for identifying patients who may have
of three to six questions. A four question version adopted
an important secondary cause of headache; a patient with
by the American Academy of Neurology includes the
a stable pattern of headache for six months is unlikely to
following questions:
have a serious underlying cause.
1. How often do you get episodes of severe headache,
i.e., is it difficult to function without treatment? Danger signs: Paying attention to danger signs is
important, since headache may be the presenting
2. How often do you get other (milder) headaches?
symptom of a space-occupying mass or vascular lesion,
3. How often do you take headache relievers or pain
infection, metabolic disturbance, or a systemic problem.
pills?
The following features in the history can serve as warning
4. Has there been any recent change in your headaches? signs of possible serious underlying disease.
In one validation study, the presence of episodic disabling Severe persistent headache that reaches maximal
headache correctly identified migraine in 136 of 146 intensity within a few seconds or minutes after the
patients (93 percent) with episodic migraine, and 154 of onset of pain warrants aggressive investigation. Sub-
197 patients (78 percent) with chronic headache with arachnoid haemorrhage, for example, often presents
migraine, with a specificity of 63 percent9,10. Only 6 of 343 with the abrupt onset of excruciating pain. In contrast,
Journal, Indian Academy of Clinical Medicine Vol. 6, No. 1 January-March, 2005 19migraine headaches generally begin with moderate as mentioned hereinbefore, patients with migraine
pain and then gradually increase to a maximal level may also have nasal symptoms7,8.
over one to two hours.
Impaired vision or seeing ‘haloes’ around light
Cluster headache may sometimes be confused with a suggests the presence of glaucoma.
serious headache, since the pain from a cluster headache
Visual field defects suggest the presence of a
can reach full intensity within minutes. However, cluster
compressed optic pathway, e.g., due to a pituitary
headache is transient (usually lasting less than one to two
mass.
hours), and is associated with characteristic ipsilateral
autonomic signs such as lacrimation or rhinorrhoea. Blurring of vision on forward bending of the head,
headaches upon waking early in the morning that
The absence of similar headache in the past is another
improve with sitting-up, and double vision, or loss of
finding that suggests a possible serious disorder. The
coordination and balance, should raise the suspicion
“first” or “worst” headache of my life’ is a description
of raised intracranial pressure. This disorder should
that sometimes accompanies an intracranial
also be considered in patients with chronic, daily,
haemorrhage or central nervous system (CNS)
progressively worsening headaches associated with
infection. On the other hand, patients suffering from
chronic nausea.
migraine usually have had similar types of headache
in the past. The presence of nausea, vomiting, worsening of
headache with changes in body position (particularly
Infection in a non-intracranial location (such as the
bending over), an abnormal neurologic examination,
lungs, or paranasal or mastoid sinuses) may serve as
and/or a significant change in prior headache pattern
a nidus for the development of meningitis or
suggest that the headache is caused by a tumour.
intracranial abscess. Fever is not a characteristic of
migraine headache; it may, however, follow a sub- Sudden, severe, unilateral vision loss suggests the
arachnoid haemorrhage by a few days. presence of optic neuritis.
Any change in mental status, personality, or Headache, fatigue, generalised aches and pain, and
fluctuation in the level of consciousness suggests a night sweats in subjects aged 55 years or older
potentially serious abnormality. suggest the presence of temporal arteritis.
The rapid onset of headache with strenuous exercise, Intermittent headache with high blood pressure is
especially when minor trauma has occurred, raises the suggestive of phaeochromocytoma.
possibility of carotid artery dissection or intracranial
haemorrhage. Physical examination: The majority of patients with
headache have a completely normal physical and
Headache that spreads into the lower neck and neurologic examination. If a complete and careful history
between the shoulders may indicate meningeal does not point to an organic aetiology, further
irritation due to either infection or sub-arachnoid examination is warranted in the following areas.
blood; it is not typical of a benign process.
Record blood pressure and pulse
New headache in patients under the age of five, or
over the age of 50, may suggest underlying pathology. Listen for bruit at neck, eyes, and head for clinical signs
of arteriovenous malformation
Other features that suggest a specific source of headache
Palpate the head, neck, and shoulder regions
include the following:
Check temporal and neck arteries
Chronic nasal stuffiness or chronic respiratory
infection suggests a diagnosis of sinusitis, although, Examine the spine and neck muscles
20 Journal, Indian Academy of Clinical Medicine Vol. 6, No. 1 January-March, 2005 A functional neurological examination including The American Academy of Neurology, American Academy
patient getting up from a seated position without any of Family Physicians, American College of Physicians,
support, walking on tiptoes and heels, cranial nerve American Society of Internal Medicine, and four other
examination, fundoscopy and otoscopy, tandem gait groups formed a consortium that took an evidence-based
and Romberg test, and symmetry on motor, sensory, approach to – among other things – evaluating the need
reflex and cerebellar (coordination) tests. for brain imaging in patients with headache11. They came
to the following conclusions:
Headache triggers
Neuroimaging should be considered in patients with
Clinical studies have identified many potential triggers non-acute headache and an unexplained abnormal
that may start an attack or worsen a pre-existing headache. finding on neurologic examination.
The role of most of these headache triggers has been well
established in terms of migraine, but remains less clear Evidence is insufficient to make specific
for other headache types. A partial list is given in Table II. recommendations in the presence or absence of
neurological symptoms, e.g., headache worsened by
There is a common belief, particularly among patients, that valsalva manoeuvre, causing awakening from sleep,
hypertension can trigger headache. While this is so in the new headache in older population, or progressively
case of hypertensive emergencies, it is probably not true worsening headache.
for typical migraine or tension headache.
Neuroimaging is usually not warranted for patients
Table II : Headache triggers. with migraine and a normal neurologic examination;
Diet Stress although, a lower threshold for imaging is warranted
Alcohol Let-down periods in patients with atypical migraine features or in
Chocolate Times of intense activity patients who do not fulfill the strict definition of
Aged cheeses Loss or change (death, migraine.
Monosodium glutamate (MSG) separation, divorce, job
Data were insufficient to make a specific
Aspartame (Nutrasweet) change)
recommendation for patients with tension-type
Caffeine Moving
headache.
Nuts Crisis
Nitrites, Nitrates Changes of environment Data were insufficient to make a specific
Hormones or habits recommendation regarding the relative sensitivity of
Menstruation Weather MRI compared with CT, in patients who have an
Ovulation Travel (crossing time zones) imaging study performed.
Hormone replacement Seasons
Given the lack of definitive data available to the guideline
(progesterone) Altitude
committee, one approach is to consider neuroimaging in
Sensory stimuli Schedule changes
the following situations:
Strong light Sleeping patterns
Flickering lights Dieting Recent significant change in the pattern, frequency,
Odours Skipping meals or severity of headache
Sounds, noise Irregular physical activity
Progressive worsening of headache despite
appropriate therapy
Indications for imaging studies
Focal neurologic signs or symptoms
Patients with any of the danger signs noted hereinbefore,
need urgent brain imaging. The vast majority of others Onset of headache with exertion, cough, or sexual
do not have secondary causes of headache, and imaging activity
is therefore not essential. Orbital bruit
Journal, Indian Academy of Clinical Medicine Vol. 6, No. 1 January-March, 2005 21 Onset of headache after 40 years of age. 5. Gil-Gouveia R, Martins IP. Headaches associated with
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Migraine Study II. Headache 2001; 41: 638.
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7. Barbanti P, Fabbrini G, Pesare M, Vanacore N. Unilateral
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8. Schreiber C, Hutchinson S, Powers C, Webster C. Physician
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