ABSTRACT
The very common symptom of headache most often has a benign cause and can usually
be diagnosed following a thorough history and neurologic and focused general physical
examinations. Because the potential etiologies can threaten life and neurological
function, headaches provoke understandable concern on the part of the patient and
health care provider. Thoughtful testing can exclude the worrisome underlying causes.
This article reviews the neurological and general symptoms and signs that should prompt
diagnostic testing and the specific diagnostic studies that are recommended. The worrisome
factors include recent head or neck injury; a new, worse, worsening, or abrupt-onset
headache; headache brought on by exertion or Valsalva maneuver/cough; new headache
in the patient over the age of 50; neurological symptoms and/or abnormal signs; systemic
symptoms and/or signs; and secondary risk factors such as a history of cancer or human
immunodeficiency virus infection. Less worrisome are headaches that wake the patient
from sleep at night, side-locked headaches, and prominent effect of change in posture
on the pain. The diagnostic investigations include neuroimaging, cerebrospinal fluid
examination, and blood testing in specific situations.
KEYWORDS
Headache - diagnostic testing - neuroimaging - guidelines
REFERENCES
- 1
Evans R W.
Diagnostic testing for the evaluation of headaches.
Neurol Clin.
1996;
14
1-26
- 2
International Headache Society Classification Subcommittee .
International classification of headache disorders, 2nd edition.
Cephalalgia.
2004;
24(suppl 1)
1-160
- 3
Frishberg B M.
The utility of neuroimaging in the evaluation of headache in patients with normal
neurologic examinations.
Neurology.
1994;
44
1191-1197
- 4
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.
Neurology.
1994;
44
1353-1354
- 5
Frishberg B M.
Neuroimaging in presumed primary headache disorders.
Semin Neurol.
1997;
17
373-382
- 6
Danish Neurological Society and the Danish Headache Society .
Guidelines for the management of headache.
Cephalalgia.
1998;
18
9-22
- 7
Field A G, Wang E.
Evaluation of the patient with nontraumatic headache: an evidence based approach.
Emerg Med Clin North Am.
1999;
17
127-152
- 8 Evans R W.
Headaches. In: Evans RW Diagnostic Testing in Neurology. Philadelphia; WB Saunders Company
1999: 1-19
- 9
Bartleson J D.
Treatment of migraine headaches.
Mayo Clin Proc.
1999;
74
702-708
- 10
Masdeu J C, Drayer B P, Anderson R E et al..
Atraumatic isolated headache: when to image.
Radiology.
2000;
215(suppl)
487-493
- 11 Frishberg B M, Rosenberg J H, Matchar D B et al.. Evidence-Based Guidelines in
the Primary Care Setting: Neuroimaging in Patients with Nonacute Headache. Minnesota:
American Academy of Neurology. 2000 Available from: http://www.aan.com/professionals/practice/pdfs/g1088.pdf Accessed November 15, 2005
- 12
Silberstein S D.
Practice parameter: evidence-based guidelines for migraine headache (an evidence-based
review).
Neurology.
2000;
55
754-763
- 13
Evans R W.
Diagnostic testing for headache.
Med Clin North Am.
2001;
85
865-885
- 14
Jamieson D G, Hargreaves R.
The role of neuroimaging in headache.
J Neuroimaging.
2002;
12
42-51
- 15
Cady R, Dodick D W.
Diagnosis and treatment of migraine.
Mayo Clin Proc.
2002;
77
255-261
- 16
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
108-122
- 17
Medina L S, D'Souza B, Vasconcellos E.
Adults and children with headache: evidence-based diagnostic evaluation.
Neuroimaging Clin N Am.
2003;
13
225-235
- 18
Cortelli P, Cevoli S, Nonino F et al..
Evidence-based diagnosis of nontraumatic headache in the emergency department: a consensus
statement on four clinical scenarios.
Headache.
2004;
44
587-595
- 19
Duarte J, Sempere A P, Delgado J A, Naranjo G, Sevillano M D, Claveria L E.
Headache of recent onset in adults: a prospective population-based study.
Acta Neurol Scand.
1996;
94
67-70
- 20
Ramirez-Lassepas M, Espinosa C E, Cicero J J, Johnston K L, Cipolle R J, Barber D L.
Predictors of intracranial pathologic findings in patients who seek emergency care
because of headache.
Arch Neurol.
1997;
54
1506-1509
- 21
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
15-17
- 22
Medina L S, Pinter J D, Zurakowski D et al..
Children with headache: clinical predictors of surgical space-occupying lesions and
the role of neuroimaging.
Radiology.
1997;
202
819-824
- 23
Lewis D W, Ashwal S, Dahl G et al..
Practice parameter: evaluation of children and adolescents with recurrent headaches.
Neurology.
2002;
59
490-498
- 24
Sudlow C.
United States guidelines on neuroimaging in patients with non-acute headache: a commentary.
J Neurol Neurosurg Psychiatry.
2002;
72(suppl 2)
ii16-ii18
- 25
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
305-307
- 26 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
2004: 265-271
- 27
Fukutake T, Mine S, Yamakami I, Yamaura A, Hattori T.
Roller coaster headache and subdural hematoma.
Neurology.
2000;
54
264
- 28
Dziewas R, Konrad C, Dräger B et al..
Cervical artery dissection: clinical features, risk factors, therapy and outcomes
in 126 patients.
J Neurol.
2003;
250
1179-1184
- 29
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
1167-1172
- 30
Milo R, Razon N, Schiffer J.
Delayed epidural hematoma: a review.
Acta Neurochir (Wien).
1987;
84
13-23
- 31
Mitchell C S, Osborn R E, Grosskreutz S R.
Computed tomography in the headache patient: is routine evaluation really necessary?.
Headache.
1993;
33
82-86
- 32
Dodick D W.
Thunderclap headache.
J Neurol Neurosurg Psychiatry.
2002;
72
6-11
- 33
Dodick D W.
Thunderclap headache.
Headache.
2002;
42
309-315
- 34
Cutrer F M, Boes C J.
Cough, exertional, and sex headaches.
Neurol Clin.
2004;
22
133-149
- 35
Pascual J, Iglesias F, Oterino A, Vazquez-Barquero A, Berciano J.
Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic
cases.
Neurology.
1996;
46
1520-1524
- 36
Kahn C E, Sanders G D, Lyons E A et al..
Computed tomography for nontraumatic headache: current utilization and cost-effectiveness.
Can Assoc Radiol J.
1993;
44
189-193
- 37
Dodick D W, Eross E J, Parish J M.
Clinical, anatomical, and physiologic relationship between sleep and headache.
Headache.
2003;
43
282-292
- 38 Adams R D, Victor M, Ropper A H. Headache and other craniofacial pains. In: Principles
of Neurology. 6th ed. New York; McGraw-Hill 1997: 171
- 39
Mokri B.
Low cerebrospinal fluid pressure syndromes.
Neurol Clin.
2004;
22
55-74
- 40
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
654-661
- 41
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
217-224
- 42
Adams H P, Kassell N F, Torner J C, Sahs A L.
CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary
report of the Cooperative Aneurysm Study.
Neurology.
1983;
33
981-988
- 43
van der Wee N, Rinkel G J, Hasan D, van Gijn J.
Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed
after a negative scan?.
J Neurol Neurosurg Psychiatry.
1995;
58
357-359
- 44
Yuan M K, Lai P H, Chen J Y et al..
Detection of subarachnoid hemorrhage at acute and subacute/chronic stages: comparison
of four magnetic resonance imaging pulse sequences and computed tomography.
J Chin Med Assoc.
2005;
68
131-137
- 45
Mohamed M, Heasly D C, Yagmurlu B, Yousem D M.
Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage: not a
panacea.
AJNR Am J Neuroradiol.
2004;
25
545-550
- 46
Practice parameter: the electroencephalogram in the evaluation of headache.
Neurology.
1995;
45
1411-1413
- 47
Smetana G W, Shmerling R H.
Does this patient have temporal arteritis?.
JAMA.
2002;
287
92-101
- 48
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
245-257
- 49
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
2-5
J.D. BartlesonM.D.
Department of Neurology, Mayo Clinic College of Medicine
200 First Street SW, Rochester, MN 55905
