Headache diagnosis

According to ICGB-2, in primary forms of headache, the anamnesis, physical and neurological examinations, and additional research methods do not reveal an organic cause of pain, i.e., they exclude the secondary nature of cephalgia. Secondary headaches are characterized by the presence of a close temporal relationship between the onset of cephalgia and the debut of the disease, an increase in the clinical manifestations of headache during exacerbations of the disease, and relief of the course of cephalgia with a decrease in symptoms or cure of the disease. The cause of headache can be established by collecting anamnesis, physical and neurological examinations, and additional research methods.

Diagnosis of primary forms of headache is based solely on complaints and anamnesis data.

Questions to ask a patient with headache

How many types of headaches do you experience? (You should ask about each one in detail)

Time of occurrence and duration	Why did you go to see a doctor now? How long have you been having headaches? How often do they occur? What kind of pain is it: episodic or chronic (constant or almost constant)? How long does it last?
Character	Intensity. The nature (quality) of pain. Localization and distribution. Harbingers (prodrome). Associated symptoms. The state after a headache attack (postdrome)
Reasons	Predisposing factors (pain triggers). Factors that aggravate and relieve headaches. History of similar headaches in the family
The impact of headache on the patient and the measures taken	Patient behavior during a headache attack. The degree of impairment of daily activities and performance during an attack. What do you take for headaches and how effective is it?
State between attacks	Are any symptoms persisting or do you feel well? Other associated (comorbid) disorders. Emotional state

Physical examination

The vast majority of patients with primary cephalgia do not show any neurological symptoms during examination. Only an attack of cluster headache is accompanied by vivid vegetative manifestations: lacrimation, rhinorrhea, sweating. Alarming symptoms in a patient during an attack of headache are hyperthermia and the presence of local neurological signs. However, in cases where the doctor has the slightest doubt about the benign nature of cephalgia attacks, as well as in the presence of symptoms, it is necessary to conduct a thorough examination (CT, MRI, EEG, ultrasound Doppler, lumbar puncture, neuro-ophthalmological examination, etc.) to exclude an organic cause of cephalgia.

Danger signals for headaches

Signal	Possible reason
Sudden onset of severe, thunderclap-like headache	Subarachnoid hemorrhage
Headache with atypical aura (lasting more than 1 hour or with symptoms of weakness in the limbs)	Transient ischemic attack or stroke
Aura without headache in a patient with no previous history of migraine	Transient ischemic attack or stroke
Aura that first appeared while taking hormonal contraceptives	Risk of stroke
New onset of headache in a patient over 50 years of age	Temporal arteritis
First-time headache in a child	Intracranial tumor
Cephalgia, progressively increasing over several weeks, months	Progressive volumetric process
Increased headache with changes in head position or loads associated with increased intracranial pressure (physical exertion, coughing, straining, sneezing)	Intracranial tumor

New onset of headache in a patient with a history of cancer, HIV infection, or immunodeficiency

Other danger signals: change in consciousness (stupor, confusion or memory loss), presence of focal neurological signs or symptoms of systemic disease (fever, arthralgia, myalgia)

Laboratory and instrumental methods of headache diagnostics

In primary cephalgias, most traditional research methods (EEG, REG, skull radiography, neuroimaging methods - CT and MRI) are uninformative, i.e. they do not reveal pathology that explains the cause of headache. In TCDG and duplex scanning of the cerebral vessels, many patients show non-specific changes: signs of venous outflow disorders, decreased blood flow velocity in the basins of some arteries, spondylogenic effects on blood flow in the vertebral arteries. X-rays of the cervical spine often reveal dystrophic and deformational changes. Additional examinations, including neuroimaging and consultations with specialists (neuro-ophthalmologist, vertebroneurologist, neurosurgeon, psychiatrist), are indicated if symptomatic forms of headache are suspected.

It should be noted that a patient may have several types of headache at the same time, therefore, one patient may be given several diagnoses (if several diagnoses are established, they should be arranged in order of importance for the patient).

If there are several types of headaches, to clarify their nature, the patient can be offered to keep a headache diary, which will help him learn to distinguish one type of headache from another. Such a diary will make it easier for the doctor to make a diagnosis and objectively assess the number of painkillers used by the patient. The following are considered primary forms of headache:

• migraine;
• tension headache;
• cluster headache and other trigeminal autonomic cephalgias;
• other primary headaches.

In addition, this section will focus on one form of benign secondary headache - medication-induced or overuse headache, which often accompanies migraine and tension headache. The incidence of overuse headache has increased significantly in recent years.

Examination for severe headache

Optimal treatment of a patient admitted to the emergency department with severe headache cannot be achieved without rapid diagnosis. The first step is to decide whether the patient is experiencing a severe attack of primary headache or whether the pain is secondary and related to a potentially dangerous disease. Certain elements of the history and physical examination are key to this differential diagnosis.

Anamnestic data indicating a connection between headache and a “serious” illness

1. If the patient has never experienced a similar headache before, the likelihood of symptomatic headache increases. If similar attacks have been noted previously for many months or years, then this rather indicates a benign condition. At the age of over 40, the likelihood of the first migraine attack decreases, and the likelihood of a tumor or other intracranial pathology increases.
2. If a headache begins suddenly, reaches its maximum intensity within a few minutes and persists for several hours, this is always a reason for a serious examination. Headaches caused by subarachnoic hemorrhage are described by patients as a sensation "as if someone hit the head with a baseball bat." With primary forms of headache, such as migraine or tension headache, the pain reaches its maximum in at least half an hour or an hour. Although with cluster headaches the sensations increase quickly, they usually persist for no longer than 3 hours.
3. If consciousness or mental status changes occur prior to or simultaneously with headache, further evaluation is necessary. Although migraineurs may appear tired, especially after prolonged vomiting or in connection with the use of large doses of analgesics, confusion or clouding of consciousness is extremely rare in primary headache. These symptoms are more likely to indicate intracranial hemorrhage or central nervous system infection, although they are also possible in such poorly defined and difficult to diagnose syndromes as basilar migraine.
4. Recent or concomitant infection in extracranial sites (e.g., lungs, paranasal sinuses, mastoid process) increases the risk of secondary headache. These infectious foci may serve as a source for subsequent development of CNS infection, such as meningitis or brain abscess.
5. If headache occurs with intense exercise or exertion or shortly after head and neck trauma, subarachnoid hemorrhage or carotid artery dissection should be considered. Exercise-induced headache and coital migraine are relatively uncommon. Rapid onset of headache with intense exercise, particularly in the presence of mild head and neck trauma, should raise suspicion for carotid artery dissection or intracranial hemorrhage.
6. Spreading pain below the neck line into the back is not typical for migraine and may indicate irritation of the meninges due to infection or hemorrhage.

Other history data that may aid in the diagnosis of severe headache

1. Family history: Migraine often runs in families, whereas secondary headaches are usually sporadic.
2. Medications taken. Some medications can cause headaches, and anticoagulants and oral antibiotics indicate the possibility of hemorrhage or untreated CNS infection.
3. History of neurological disorders. Previous residual neurological symptoms may complicate the interpretation of examination findings.
4. Localization of headache. Benign headaches tend to change side and location, at least sometimes.

Diagnostically important examination data

1. Neck stiffness suggests meningitis or subarachnoid hemorrhage.
2. Edema of the optic discs is a sign of increased intracranial pressure, indicating the possibility of a tumor or hemorrhage and, therefore, signaling the need for further examination.
3. Any disturbance of consciousness or orientation of any nature requires urgent additional examination.
4. External signs of intoxication. Fever is not typical for primary headache. Even a slight increase in body temperature, as well as persistent tachycardia or bradycardia should be regarded as signs of a possible infectious disease.
5. Any previously unnoticed neurological symptom.

New symptoms, such as slight pupillary asymmetry, lowering of the arm with its internal rotation in the Barre test, pathological foot sign increase the probability of detecting a serious intracranial disease. It is important to examine the patient dynamically at short intervals, since the neurological status may change.

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