Each year, headaches are experienced by about half of all adults.
A thorough patient interview is the cornerstone of the headache workup.
If the headache symptoms of a healthy adult are consistent with a known primary headache (ICHD-3 classification) and the findings on general clinical and neurological examination are normal, further investigations are usually not warranted.
Epidemiology and classification
Of the primary headaches in adults, tension-type headache (with a prevalence of 63%) and migraine (15%) are the most common.
The classification of headaches into primary and secondary headaches and other states of pain in the head area is based on the criteria specified in the 2018 ICHD-3 (International Classification of Headache Disorders) http://ichd-3.org.
Daily or almost daily headache caused by several concurring different headache disorders, such as chronic migraine, chronic tension-type headache, excessive use of analgesics and often some other disease causing headache.
In the case of chronic daily headache, it is most important to start prophylactic treatment of the primary headache, to stop excessive use of analgesics and to observe any secondary causes (such as sleep apnoea, hypertension or causes related to occlusion).
Diagnostic work-up of the headache symptom
Assess the headache symptom on the basis of patient history.
Examine the patient carefully for general and neurological status.
Evaluate the need for any further investigations or consultations.
Plan medication to treat attacks and begin prophylactic medication, as necessary.
Provide patient guidance.
History and status of the headache patient
Duration and type of headache attack
Headache getting worse on physical exertion and continuing for 1-3 days is typical for migraine. A constant dull aching feeling as if something is being tightened around the head is consistent with tension-type headache.
Short-term unilateral, very intense, localized pain is typical for cluster headache (30-180 min) or for an attack of neuralgic pain, such as trigeminal neuralgia (seconds).
Onset of symptoms
Sudden onset (in minutes) is typical for SAH and cluster headache. Migraine pain grows more intense either quickly, within an hour, or slowly, over several hours.
Pain becoming slowly more intense and disturbing in the afternoon is typical for tension-type headache.
Expanding brain processes increasing intracranial pressure give symptoms in the small hours and on physical exertion.
Rate of occurrence, recurrence
Recurring similar headaches are often migraine or tension-type headaches.
Episodes recurring within a day are typical for cluster headache and often begin after falling asleep. Periods of pain may continue from several weeks to several months.
Location of the pain
Migraine is often and cluster headache attacks are invariably unilateral.
Occipital and temporal pain is often associated with tension-type headache.
Causes underlying unilateral temporal headache may be associated with the neck, sinusitis, giant cell arteritis (temporal arteritis) Giant Cell (Temporal) Arteritis or disorders of the temporomandibular joint or malocclusion Malocclusion and Headache.
Eye pain may be associated with intraocular pressure or optic neuritis and requires examination by an ophthalmologist.
Nature of the pain
Pulsating pain getting worse on physical exertion is associated with migraine; tension-type headache feels like a band tightening around the head.
Pain waking the patient up in the small hours is often due to migraine or to an increase in intracranial pressure Increased Intracranial Pressure.
Cutting pain in the eye region and lacrimation are associated with trigeminal autonomic cephalalgias, such as cluster headache.
Symptoms associated with the headache
Tiredness, yawning and craving for sweets are typical prodromal symptoms of migraine.
Nausea and sensory sensitivity are associated with migraine.
The aura symptom of migraine is typically an expanding, bright scintillating visual disturbance continuing for less than an hour, rarely also unilateral numbness or difficulty of speech.
In patients with visual aura symptoms, symptoms of transient ischaemic attack (TIA) must be considered for differential diagnosis Transient Ischaemic Attack (TIA).
In TIA, there is sudden vision loss in the visual field or parts of it, and usually no bright scintillation.
Numbness, motor paralysis or speech symptoms are typical of TIA.
There is no nausea or vomiting in tension-type headache. If these symptoms occur, a migraine attack is also present or the nausea may be associated with increased intracranial pressure.
Provoking and alleviating factors
A migraine attack may be triggered by a change in the amount of mental stress or by alcohol, as well as by odours or bright lights.
During a migraine attack, rest in a dark place helps the patient feel better.
Physical activity often alleviates tension-type headache.
Medication history
Note medication used daily or for symptomatic treatment, with doses and dosing frequency
Frequent use of analgesics (triptans on 10 or more days a month, NSAIDs or paracetamol on 15 or more days a month, opioids) is associated with a considerable risk of analgesic rebound headache in patients with migraine.
Analgesic rebound headache should be treated by withdrawal of medication either alone or combined with initiation of prophylactic medication.
Clinical examination
A clinical examination should be performed in a non-urgent setting; it will give normal results between attacks.
In cluster headache, Horner's syndrome (ptosis, miosis, enophthalmus) can be seen in the eye ipsilateral to the pain during the attack, as well as ipsilateral lacrimation and nasal discharge, and sometimes facial sweating.
Blood pressure should be measured in all patients.
Intraocular pressure should be measured in cases of a headache in the eye area.
In examination of the ocular fundi, irregularity of the edge of the papilla and the absence of venous pulsation (papillary stasis) may suggest elevated intracranial pressure requiring further investigations.
Further investigations
Primary headache disorders, such as migraine and tension-type headache, are diagnosed on the basis of history and clinical examination.
If necessary for differential diagnosis, test selectively the following parameters:
Basic blood count with platelet count
ESR
TSH and/or free T4
Fasting plasma glucose
Sodium, potassium, albumin-corrected calcium
Creatinine
Patients with symptoms of infection should be examined by ultrasonography or x-ray of the maxillary and frontal sinuses.
Examination of the cerebrospinal fluid should be performed if there are symptoms of meningitis or other CNS symptoms Lumbar Puncture.
In suspected SAH, brain CT and cerebral angiography should be performed. If brain CT scan is normal in a patient with suspected SAH, the condition can be excluded by performing a lumbar puncture, as considered necessary.
Indications for referral for further examinations
Emergency referral is indicated if meningitis, encephalitis or SAH is suspected.
Emergency consultation is indicated if the status is abnormal, e.g. there is a personality change, diplopia, papillary stasis, asymmetric reflexes.
The patient should be referred to specialized care if
headache is continuous even though the patient's status is normal
headache occurs in connection with physical strain or coughing
the patient needs withdrawal treatment for analgesics and/or triptans
the headache does not respond to medication
the headache causes inability to work.
Treatment of headache
Treatment of headache is discussed separately in the articles on the different types of headache.
Stovner LJ, Hagen K, Linde M et al. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. J Headache Pain 2022;23(1):34. [PubMed]