What is the appropriate workup for a patient presenting with a headache?

From the Guidelines

The workup for a headache should begin with a thorough history and physical examination to determine the headache type and identify any concerning features. This approach is crucial in distinguishing between primary headaches that can be managed conservatively and secondary headaches that may require urgent intervention 1. When evaluating a patient with a headache, it is essential to assess the headache's character (throbbing, pressure, stabbing), location, duration, frequency, severity, associated symptoms, triggers, and relieving factors.

Key Components of the History and Physical Examination

• Assessing the headache's character, location, duration, frequency, severity, associated symptoms, triggers, and relieving factors
• Performing a complete neurological examination including fundoscopy to check for papilledema
• Identifying any concerning features such as sudden-onset severe headache, headache with fever, focal neurological deficits, altered mental status, or headache in immunocompromised patients

According to the International Headache Society Classification of Headaches, migraines are diagnosed based on specific criteria, including unilateral location, throbbing character, worsening pain with routine activity, and moderate to severe intensity, among others 1. Tension headaches, on the other hand, are characterized by pressing, tightening, or nonpulsatile character, mild to moderate intensity, and bilateral location.

Neuroimaging and Laboratory Tests

• Urgent neuroimaging with CT or MRI is indicated for patients with concerning features such as sudden-onset severe headache, headache with fever, focal neurological deficits, altered mental status, or headache in immunocompromised patients
• Laboratory tests may include complete blood count, metabolic panel, ESR/CRP for suspected temporal arteritis, and lumbar puncture if meningitis or subarachnoid hemorrhage is suspected
• For primary headaches like migraine or tension headaches without concerning features, neuroimaging is generally not required, as suggested by the American Academy of Neurology and the U.S. Headache Consortium 1

Treatment

• Treatment should target the specific headache type identified
• For migraines, acute treatments include NSAIDs (ibuprofen 400-600mg), acetaminophen (1000mg), triptans (sumatriptan 50-100mg), or combination medications
• Preventive therapy should be considered for frequent or disabling headaches, with options including propranolol (40-160mg daily), topiramate (25-100mg twice daily), amitriptyline (10-75mg nightly), or newer CGRP antagonists 1

From the Research

Headache Workup

• A thorough and methodical headache history is the mainstay for diagnosis of both primary and secondary headache disorders 2
• Evaluation and workup should include a complete neurological examination, consideration of neuroimaging in specific limited situations, and serum or spinal fluid analysis if indicated 2, 3
• A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache 4

Diagnostic Approach

• Adopting a diagnostic approach to headache ensures that cannot-miss, or potentially fatal, headache syndromes are not overlooked, while resource-intensive tests are performed only on an as-needed basis 2
• Evaluating acute headaches using a systematic framework such as the SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches 4
• Red flag signs or symptoms such as acute thunderclap headache, fever, meningeal irritation on physical examination, papilledema with focal neurologic signs, impaired consciousness, and concern for acute glaucoma warrant immediate evaluation 4, 3

Neuroimaging

• Noncontrast computed tomography of the head is recommended to exclude acute intracranial hemorrhage or mass effect in emergent evaluations 4
• A lumbar puncture is also needed to rule out subarachnoid hemorrhage if the scan result is normal 4
• Magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features in less urgent cases 4
• Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging 4, 3

Management

• Proper categorisation of the primary headache, attention to lifestyle and psychosocial factors, prescription of analgesics for acute pain relief, and the use of preventive medication when indicated are key steps in managing primary headache 5
• The patient with a cluster headache, a headache of uncertain diagnosis and/or poor response to preventive strategies or a migraine with persistent aura, or a headache with associated motor weakness, should be referred to a neurologist 5