How Headaches Are Diagnosed

Bin TrumpJuly 12, 2019

Diagnosis of a headache takes several things into account, including when episodes occur, what symptoms you experience, how they respond to treatments you’ve tried, your overall health profile, and more. By performing a detailed history and physical exam, and perhaps some testing, your physician will work to identify what type of headache you are experiencing or, if a headache disorder is not at the root of your pain, what other condition may be causing it.

Assessment
Your doctor will do a physical examination, which will give details as to your blood pressure and cardiorespiratory functions. A neurological examination will also evaluate your sensory responses, muscle and nerve function, and coordination and balance. Your health care provider will also make note of your personal and family medical history, any medications you are taking, and your lifestyle habits (e.g., caffeine intake, alcohol use, smoking).

When evaluating you, your doctor will first likely ask you several specific questions about your headache. These questions include:

Location: Where is the pain located?
Onset: Was the onset of your head pain rapid or gradual?
Duration: How long has the pain been going on for? Is the pain constant or intermittent?
Character: How would you describe your headache? (e.g., throbbing, aching, burning, or sharp)
Severity: What is your pain on a scale of 1 to 10? Would you describe your headache as mild, moderate, or severe? Is this the worst headache of your life?
Radiation: Does the pain radiate? If so, where?
Exacerbating or alleviating factors: What makes the pain better or worse?
Associations: Are there other symptoms associated with your headache? (e.g., nausea, vomiting, visual changes)
Additionally, other tools your doctor may use in diagnosing your headache include the POUND mnemonic or the ID Migraine Questionnaire.

How Cluster Headaches Are Different

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Based on this information, your health care provider can decide whether or not your headache is a type of primary headache disorder—the three most common of which are migraines, tension-type headaches, and cluster headaches—or possibly due to something else.1

An Overview of Headaches
Labs and Tests
You may have blood and urine tests to assess your basic health and rule out causes of secondary headaches, such as infection, dehydration, diabetes, or thyroid disorders. There aren’t lab tests that are specific for diagnosing primary headache disorders.

If an infection of brain or spinal cord is suspected, your doctor may do a spinal tap to assess the pressure of the fluid and analyze it for infectious agents.

Your doctor may do an electroencephalogram (EEG) if your headaches have had any symptoms of seizures.

Imaging
Although they are not a routine part of a headache workup, your doctor may order imaging tests if you have symptoms that point to a structural cause for your headaches. This may be recommended if you have headaches almost every day or if your doctor thinks you may have sinus problems. Imaging procedures might include X-rays, CT scan, or MRI.

Diagnosing Tension-Type Headaches
Tension-type headaches are usually bilateral, non-pulsating, are not exacerbated by routine physical activity, and are not associated with nausea or auras.2 They can be associated with photophobia or phonophobia.

Please note that according to the criteria created by International Classification of Headache Disorders tension-type headaches can only be associated with either photophobia or phonophobia, not both.

Frequent tension-type headaches often coexist with migraines without auras so maintaining a headache diary is critical, as a treatment for these conditions is distinct.

Character: Pressing, tightening, “rubber-band-like sensation” around the head
Severity: Mild to moderate
Exacerbating or Alleviating factors: Usually alleviated with over-the-counter analgesics, like acetaminophen or NSAIDs. Smoking is one potential exacerbating factor, especially for those suffering from chronic tension-type headaches.2
Radiation: Variable but commonly patients describe the pain as radiating from the back of the head into their neck muscles.
Onset: Gradual (usually a more gradual onset than that of a migraine)
Duration: Minutes to days (30 minutes to 7 days according to criteria from the International Headache Society)
Associations: No nausea but may be associated with either photophobia or phonophobia
Location: Bilateral
Overview of Tension Headaches
Diagnosing Cluster Headaches
A cluster headache, also known as a “suicide headache,” due to its severe, debilitating intensity, plagues men more than women.

These headaches occur in clusters or periods of time that typically last from one week to one year followed by pain-free periods of at least one month.

During an episodic cluster headache, the sufferer can experience multiple attacks, typically up to eight days. Some individuals suffer from chronic cluster headaches, in which a cluster headache period will last for more than one year without any pain-free periods or pain-free periods that are less than one month.3

Character: Sharp, burning, piercing
Severity: Severe to very severe
Exacerbating or Alleviating factors: Alcohol, histamine, and nitroglycerin are examples of exacerbating factors, especially in chronic cluster headaches. Triptans and oxygen are potential acute therapies for cluster headaches.
Radiation: Variable
Onset: Rapid
Duration: If untreated, lasts 15-80 minutes, according to criteria from the International Headache Society.
Associations: Associated with autonomic symptoms including ipsilateral or same-sided conjunctival injection and/or eye tearing, nasal congestion and/or discharge, eyelid swelling, forehead and facial sweating, miosis and/or ptosis, and agitation and/or restlessness.
Location: Strictly unilateral and either orbital or supraorbitalDiagnosing Migraines
Migraines are more than just headaches. A migraine is a common, neurologic condition that may or may not be associated with a migraine aura, a disturbance that classically causes visual symptoms, but also may include other neurologic symptoms, like sensory or speech alterations.4

Character: Throbbing, pulsating
Severity: Moderate or severe
Exacerbating or Alleviating factors: Bright lights or loud noises may be exacerbating while NSAIDs, triptans, and sleep are common migraine alleviators.4
Radiation: Variable
Onset: Gradual (although usually not as gradual of onset as that of a tension-type headache).
Duration: 4-72 hours
Associations: Nausea, vomiting, phonophobia, photophobia, migraine aura (up to 1/3 of migraineurs)
Location: Unilateral (typically)

Overview of Migraines
Differential Diagnoses
Your doctor will consider whether there might be an infectious cause for a headache. You might have a headache with many types of viral, bacterial, fungal, or parasitic infections.5 Of special concern are infections of the brain or spinal cord.

A stroke, hemorrhage, or blood clot in the brain is a serious condition that might present with a headache, and your doctor will want to ensure it isn’t missed.6 High blood pressure or recent trauma might lead to these problems.

There may be a structural cause for the headache, such as a tumor, abscess, or buildup of fluid in the brain. A headache can also be the result of taking pain medication too often.7

A Word From Verywell
When assessing your headache disorder, your doctor will likely ask you several of the above questions in order to best understand your symptoms. It may be a good idea to even write down answers prior to your visit, so you are best prepared. Try to be thorough and proactive when evaluating your own headaches, so that together you and your doctor can create an effective treatment plan.

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