Download PDF
Semin Neurol 2010; 30(2): 131-144
DOI: 10.1055/s-0030-1249221
© Thieme Medical Publishers

When and How to Investigate the Patient with Headache

G.C. De Luca1 , J.D. Bartleson1
  • 1Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
Further Information

Publication History

Publication Date:
29 March 2010 (online)

    Permissions and Reprints

ABSTRACT

The common complaint of headache usually has a benign cause, most often a primary headache syndrome. The history and neurologic and general physical examinations usually permit a definitive diagnosis. When in doubt, diagnostic testing is indicated. Certain historical and examination findings increase the likelihood of a secondary headache disorder and the need for diagnostic testing. These include (1) recent head or neck injury; (2) a new, worse, worsening, or abrupt onset headache; (3) headache brought on by Valsalva maneuver or cough; (4) headache brought on by exertion; (5) headache associated with sexual activity; (6) pregnancy; (7) headache in the patient over the age of ~50; (8) neurologic findings and/or symptoms; (9) systemic signs and/or symptoms; (10) secondary risk factors, such as cancer or human immunodeficiency virus (HIV) infection. Less worrisome are headaches that wake the patient from sleep at night, always occur on the same side, or show a prominent effect of change in posture on the patient's pain. Diagnostic studies include neuroimaging, cerebrospinal fluid (CSF) examination, and blood tests, which are selected depending on the patient's history and findings. For most patients, the diagnostic test of choice is a magnetic resonance imaging (MRI) brain scan. Computed tomography (CT) of the brain is usually obtained in the setting of trauma or the abrupt onset of headache. CSF examination is useful in diagnosing subarachnoid bleeding, infection, and high and low CSF pressure syndromes.

KEYWORDS

Headache - diagnostic testing - investigation - neuroimaging - guidelines

REFERENCES

  • 1 Evans R W. Diagnostic testing for the evaluation of headaches.  Neurol Clin. 1996;  14(1) 1-26
    CrossrefPubMedGoogle Scholar
  • 2 Headache Classification Subcommittee of the International Headache Society . The international classification of headache disorders, 2nd edition.  Cephalalgia. 2004;  24(Suppl 1) 1-160
    PubMedGoogle Scholar
  • 3 Bartleson J D. When and how to investigate the patient with headache.  Semin Neurol. 2006;  26(2) 163-170
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Evans R W. Diagnostic testing for headache.  Med Clin North Am. 2001;  85(4) 865-885
    CrossrefPubMedGoogle Scholar
  • 5 Frishberg B M. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations.  Neurology. 1994;  44(7) 1191-1197
    PubMedGoogle Scholar
  • 6 Danish Neurological Society and the Danish Headache Society . Guidelines for the management of headache.  Cephalalgia. 1998;  18(1) 9-22
    CrossrefPubMedGoogle Scholar
  • 7 Field A G, Wang E. Evaluation of the patient with nontraumatic headache: an evidence based approach.  Emerg Med Clin North Am. 1999;  17(1) 127-152, ix
    CrossrefPubMedGoogle Scholar
  • 8 Locker T E, Thompson C, Rylance J, Mason S M. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department.  Headache. 2006;  46(6) 954-961
    CrossrefPubMedGoogle Scholar
  • 9 Report of the Quality Standards Subcommittee of the American Academy of Neurology . Practice parameter: the utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations (summary statement).  Neurology. 1994;  44(7) 1353-1354
    PubMedGoogle Scholar
  • 10 Bartleson J D. Treatment of migraine headaches.  Mayo Clin Proc. 1999;  74(7) 702-708
    CrossrefPubMedGoogle Scholar
  • 11 Masdeu J C, Drayer B P, Anderson R E et al.. Atraumatic isolated headache—when to image. American College of Radiology. ACR Appropriateness Criteria.  Radiology. 2000;  215(Suppl) 487-493
    PubMedGoogle Scholar
  • 12 Frishberg B M. Neuroimaging in presumed primary headache disorders.  Semin Neurol. 1997;  17(4) 373-382
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Silberstein S D. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.  Neurology. 2000;  55(6) 754-762
    CrossrefPubMedGoogle Scholar
  • 14 Jamieson D G, Hargreaves R. The role of neuroimaging in headache.  J Neuroimaging. 2002;  12(1) 42-51
    CrossrefPubMedGoogle Scholar
  • 15 American College of Emergency Physicians . Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache.  Ann Emerg Med. 2002;  39(1) 108-122
    CrossrefPubMedGoogle Scholar
  • 16 Medina L S, D'Souza B, Vasconcellos E. Adults and children with headache: evidence-based diagnostic evaluation.  Neuroimaging Clin N Am. 2003;  13(2) 225-235
    CrossrefPubMedGoogle Scholar
  • 17 Cortelli P, Cevoli S, Nonino F Multidisciplinary Group for Nontraumatic Headache in the Emergency Department et al. Evidence-based diagnosis of nontraumatic headache in the emergency department: a consensus statement on four clinical scenarios.  Headache. 2004;  44(6) 587-595
    CrossrefPubMedGoogle Scholar
  • 18 Evans R W. Headaches. In: Evans RW Diagnostic Testing in Neurology. Philadelphia; WB Saunders Company 1999: 1-19
    Google Scholar
  • 19 Sudlow C. US guidelines on neuroimaging in patients with non-acute headache: a commentary.  J Neurol Neurosurg Psychiatry. 2002;  72(Suppl 2) ii16-ii18
    PubMedGoogle Scholar
  • 20 Lewis D W, Ashwal S, Dahl G Quality Standards Subcommittee of the American Academy of Neurology et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.  Neurology. 2002;  59(4) 490-498
    CrossrefPubMedGoogle Scholar
  • 21 Tynecka-Turowska M, Krasińska-Czerlunczakiewicz H, Mitosek-Szewczyk K, Stelmasiak Z. The use of instrumental examinations in the diagnosis of headaches.  Neurol Sci. 2003;  24(4) 305-307
    CrossrefPubMedGoogle Scholar
  • 22 Bartleson J D, Black D F, Swanson J W. Cranial and facial pain. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J Neurology in Clinical Practice: Principles of Diagnosis and Management. Vol. 1. Philadelphia; Butterworth-Heinemann 2008: 263-269
    Google Scholar
  • 23 Milo R, Razon N, Schiffer J. Delayed epidural hematoma. A review.  Acta Neurochir (Wien). 1987;  84(1-2) 13-23
    CrossrefPubMedGoogle Scholar
  • 24 Dziewas R, Konrad C, Dräger B et al.. Cervical artery dissection—clinical features, risk factors, therapy and outcome in 126 patients.  J Neurol. 2003;  250(10) 1179-1184
    CrossrefPubMedGoogle Scholar
  • 25 Caplan J M, Khalpey Z, Gates J. Closed traumatic head injury: dural sinus and internal jugular vein thrombosis.  Emerg Med J. 2008;  25(11) 777-778
    CrossrefPubMedGoogle Scholar
  • 26 Mills M L, Russo L S, Vines F S, Ross B A. High-yield criteria for urgent cranial computed tomography scans.  Ann Emerg Med. 1986;  15(10) 1167-1172
    CrossrefPubMedGoogle Scholar
  • 27 Bordignon K C, Arruda W O. CT scan findings in mild head trauma: a series of 2,000 patients.  Arq Neuropsiquiatr. 2002;  60(2-A, 2-A) 204-210
    PubMedGoogle Scholar
  • 28 Duarte J, Sempere A P, Delgado J A, Naranjo G, Sevillano M D, Clavería L E. Headache of recent onset in adults: a prospective population-based study.  Acta Neurol Scand. 1996;  94(1) 67-70
    CrossrefPubMedGoogle Scholar
  • 29 Dodick D W. Thunderclap headache.  J Neurol Neurosurg Psychiatry. 2002;  72(1) 6-11
    CrossrefPubMedGoogle Scholar
  • 30 Dodick D W. Thunderclap headache.  Headache. 2002;  42(4) 309-315
    CrossrefPubMedGoogle Scholar
  • 31 Landtblom A M, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes.  Cephalalgia. 2002;  22(5) 354-360
    CrossrefPubMedGoogle Scholar
  • 32 Dupont S A, Wijdicks E F, Manno E M, Rabinstein A A. Thunderclap headache and normal computed tomographic results: value of cerebrospinal fluid analysis.  Mayo Clin Proc. 2008;  83(12) 1326-1331
    CrossrefPubMedGoogle Scholar
  • 33 Edlow J A, Caplan L R. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage.  N Engl J Med. 2000;  342(1) 29-36
    CrossrefPubMedGoogle Scholar
  • 34 Matharu M S, Schwedt T J, Dodick D W. Thunderclap headache: an approach to a neurologic emergency.  Curr Neurol Neurosci Rep. 2007;  7(2) 101-109
    CrossrefPubMedGoogle Scholar
  • 35 Schwedt T J, Matharu M S, Dodick D W. Thunderclap headache.  Lancet Neurol. 2006;  5(7) 621-631
    CrossrefPubMedGoogle Scholar
  • 36 Cutrer F M, Boes C J. Cough, exertional, and sex headaches.  Neurol Clin. 2004;  22(1) 133-149
    CrossrefPubMedGoogle Scholar
  • 37 Sands G H, Newman L, Lipton R. Cough, exertional, and other miscellaneous headaches.  Med Clin North Am. 1991;  75(3) 733-747
    PubMedGoogle Scholar
  • 38 Pascual J, González-Mandly A, Martín R, Oterino A. Headaches precipitated by cough, prolonged exercise or sexual activity: a prospective etiological and clinical study.  J Headache Pain. 2008;  9(5) 259-266
    CrossrefPubMedGoogle Scholar
  • 39 Pascual J, Iglesias F, Oterino A, Vázquez-Barquero A, Berciano J. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases.  Neurology. 1996;  46(6) 1520-1524
    PubMedGoogle Scholar
  • 40 Evers S, Lance J W. Primary headache attributed to sexual activity. In: Olesen J, Goadsby PJ, Ramadan NM et al The Headaches. 3rd Ed. Philadelphia; Lippincott Williams & Wilkins 2006: 841-845
    Google Scholar
  • 41 Locksley H B. Natural history of subarachnoid hemorrhage, intracranial aneurysms, and arteriovenous malformations. In: Sahs AL, Perret GE, Locksley HB et al Intracranial Aneurysms and Subarachnoid Hemorrhage. Philadelphia; Lippincott 1969: 37-57
    Google Scholar
  • 42 Lundberg P O, Osterman P O. The benign and malignant forms of orgasmic cephalgia.  Headache. 1974;  14(3) 164-165
    CrossrefPubMedGoogle Scholar
  • 43 Lance J W, Anthony M. Some clinical aspects of migraine. A prospective survey of 500 patients.  Arch Neurol. 1966;  15(4) 356-361
    PubMedGoogle Scholar
  • 44 Somerville B W. A study of migraine in pregnancy.  Neurology. 1972;  22(8) 824-828
    PubMedGoogle Scholar
  • 45 Chen T C, Leviton A. Headache recurrence in pregnant women with migraine.  Headache. 1994;  34(2) 107-110
    CrossrefPubMedGoogle Scholar
  • 46 Menon R, Bushnell C D. Headache and pregnancy.  Neurologist. 2008;  14(2) 108-119
    CrossrefPubMedGoogle Scholar
  • 47 Bousser M G, Barnett H J. Cerebral venous thrombosis. In: Mohr JP, Choi DW, Grotta JC et al Stroke: Pathophysiology, Diagnosis, and Management. Philadelphia; Churchill Livingstone 2004: 301-325
    Google Scholar
  • 48 Standards A CR. MRI safety and sedation. Available at www://http.acr.org Accessed June 30, 2009
    Google Scholar
  • 49 Bigal M E, Lipton R B. The differential diagnosis of chronic daily headaches: an algorithm-based approach.  J Headache Pain. 2007;  8(5) 263-272
    CrossrefPubMedGoogle Scholar
  • 50 Harris J E, Draper H L, Rhodes A I, Stevens J M. High yield criteria for emergency cranial computed tomography in adult patients with no history of head injury.  J Accid Emerg Med. 2000;  17(1) 15-17
    PubMedGoogle Scholar
  • 51 Kahn Jr C E, Sanders G D, Lyons E A, Kostelic J K, MacEwan D W, Gordon W L. Computed tomography for nontraumatic headache: current utilization and cost-effectiveness.  Can Assoc Radiol J. 1993;  44(3) 189-193
    PubMedGoogle Scholar
  • 52 Edmeads J. Headaches in older people. How are they different in this age-group?.  Postgrad Med. 1997;  101(5) 91-94, 98–100
    PubMedGoogle Scholar
  • 53 Mitchell C S, Osborn R E, Grosskreutz S R. Computed tomography in the headache patient: is routine evaluation really necessary?.  Headache. 1993;  33(2) 82-86
    CrossrefPubMedGoogle Scholar
  • 54 Cohen A S, Kaube H. Rare nocturnal headaches.  Curr Opin Neurol. 2004;  17(3) 295-299
    CrossrefPubMedGoogle Scholar
  • 55 Dodick D W, Eross E J, Parish J M, Silber M. Clinical, anatomical, and physiologic relationship between sleep and headache.  Headache. 2003;  43(3) 282-292
    CrossrefPubMedGoogle Scholar
  • 56 Gil-Gouveia R, Goadsby P J. Secondary “hypnic headache”.  J Neurol. 2007;  254(5) 646-654
    CrossrefPubMedGoogle Scholar
  • 57 Medina L S, Pinter J D, Zurakowski D, Davis R G, Kuban K, Barnes P D. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging.  Radiology. 1997;  202(3) 819-824
    PubMedGoogle Scholar
  • 58 Leone M, Cecchini A P, Mea E, Tullo V, Bussone G. Epidemiology of fixed unilateral headaches.  Cephalalgia. 2008;  28(Suppl 1) 8-11
    CrossrefPubMedGoogle Scholar
  • 59 Prakash S, Shah N D, Soni R K. Secondary hemicrania continua: case reports and a literature review.  J Neurol Sci. 2009;  280(1-2) 29-34
    CrossrefPubMedGoogle Scholar
  • 60 Evans R W. Hemicrania continua-like headache due to nonmetastatic lung cancer—a vagal cephalalgia.  Headache. 2007;  47(9) 1349-1351
    CrossrefPubMedGoogle Scholar
  • 61 Mokri B. Low cerebrospinal fluid pressure syndromes.  Neurol Clin. 2004;  22(1) 55-74, vi , vi
    CrossrefPubMedGoogle Scholar
  • 62 Leep Hunderfund A N, Mokri B. Orthostatic headache without CSF leak.  Neurology. 2008;  71(23) 1902-1906
    CrossrefPubMedGoogle Scholar
  • 63 Ropper A H, Samuels M A. Headache and other craniofacial pains. In: Principles of Neurology. New York; McGraw-Hill 2009: 178
    Google Scholar
  • 64 Ferrari A. Headache: one of the most common and troublesome adverse reactions to drugs.  Curr Drug Saf. 2006;  1(1) 43-58
    CrossrefPubMedGoogle Scholar
  • 65 Karachalios G N, Charalabopoulos A, Papalimneou V et al.. Withdrawal syndrome following cessation of antihypertensive drug therapy.  Int J Clin Pract. 2005;  59(5) 562-570
    CrossrefPubMedGoogle Scholar
  • 66 Askmark H, Lundberg P O, Olsson S. Drug-related headache.  Headache. 1989;  29(7) 441-444
    CrossrefPubMedGoogle Scholar
  • 67 Hopkins S, Jolles S. Drug-induced aseptic meningitis.  Expert Opin Drug Saf. 2005;  4(2) 285-297
    CrossrefPubMedGoogle Scholar
  • 68 Jolles S, Sewell W A, Leighton C. Drug-induced aseptic meningitis: diagnosis and management.  Drug Saf. 2000;  22(3) 215-226
    CrossrefPubMedGoogle Scholar
  • 69 Østensen M, Villiger P M. Nonsteroidal anti-inflammatory drugs in systemic lupus erythematosus.  Lupus. 2001;  10(3) 135-139
    CrossrefPubMedGoogle Scholar
  • 70 Nettis E, Calogiuri G, Colanardi M C, Ferrannini A, Tursi A. Drug-induced aseptic meningitis.  Curr Drug Targets Immune Endocr Metabol Disord. 2003;  3(2) 143-149
    CrossrefPubMedGoogle Scholar
  • 71 Vernooij M W, Ikram M A, Tanghe H L et al.. Incidental findings on brain MRI in the general population.  N Engl J Med. 2007;  357(18) 1821-1828
    CrossrefPubMedGoogle Scholar
  • 72 Sandrini G, Friberg L, Jänig W et al.. Neurophysiological tests and neuroimaging procedures in non-acute headache: guidelines and recommendations.  Eur J Neurol. 2004;  11(4) 217-224
    CrossrefPubMedGoogle Scholar
  • 73 Detsky M E, McDonald D R, Baerlocher M O, Tomlinson G A, McCrory D C, Booth C M. Does this patient with headache have a migraine or need neuroimaging?.  JAMA. 2006;  296(10) 1274-1283
    CrossrefPubMedGoogle Scholar
  • 74 Rothrock S G, Buchanan C, Green S M, Bullard T, Falk J L, Langen M. Cranial computed tomography in the emergency evaluation of adult patients without a recent history of head trauma: a prospective analysis.  Acad Emerg Med. 1997;  4(7) 654-661
    CrossrefPubMedGoogle Scholar
  • 75 Sempere A P, Porta-Etessam J, Medrano V et al.. Neuroimaging in the evaluation of patients with non-acute headache.  Cephalalgia. 2005;  25(1) 30-35
    CrossrefPubMedGoogle Scholar
  • 76 Edlow J A. Diagnosis of subarachnoid hemorrhage in the emergency department.  Emerg Med Clin North Am. 2003;  21(1) 73-87
    CrossrefPubMedGoogle Scholar
  • 77 Report of the Quality Standards Subcommittee of the American Academy of Neurology . Practice parameter: the electroencephalogram in the evaluation of headache (summary statement).  Neurology. 1995;  45(7) 1411-1413
    PubMedGoogle Scholar
  • 78 Smetana G W, Shmerling R H. Does this patient have temporal arteritis?.  JAMA. 2002;  287(1) 92-101
    CrossrefPubMedGoogle Scholar
  • 79 Costello F, Zimmerman M B, Podhajsky P A, Hayreh S S. Role of thrombocytosis in diagnosis of giant cell arteritis and differentiation of arteritic from non-arteritic anterior ischemic optic neuropathy.  Eur J Ophthalmol. 2004;  14(3) 245-257
    PubMedGoogle Scholar
  • 80 Eross E J, Dodick D W, Swanson J W, Capobianco D J. A review of intractable facial pain secondary to underlying lung neoplasms.  Cephalalgia. 2003;  23(1) 2-5
    CrossrefPubMedGoogle Scholar
  • 81 Brenner D J, Hall E J. Computed tomography—an increasing source of radiation exposure.  N Engl J Med. 2007;  357(22) 2277-2284
    CrossrefPubMedGoogle Scholar
  • 82 Perez-Rodriguez J, Lai S, Ehst B D, Fine D M, Bluemke D A. Nephrogenic systemic fibrosis: incidence, associations, and effect of risk factor assessment—report of 33 cases.  Radiology. 2009;  250(2) 371-377
    CrossrefPubMedGoogle Scholar
  • 83 Kaufmann T J, Huston III J, Mandrekar J N, Schleck C D, Thielen K R, Kallmes D F. Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients.  Radiology. 2007;  243(3) 812-819
    CrossrefPubMedGoogle Scholar

J.D. BartlesonM.D. 

Associate Professor of Neurology, Mayo Clinic College of Medicine, Mayo Building

8th floor, 200 First Street SW, Rochester, MN, 55905

Email: bartleson.john@mayo.edu