What investigations are recommended for patients presenting with chronic headaches?

From the Guidelines

The investigation of chronic headaches should be tailored to the clinical presentation, with a thorough clinical assessment and headache diary being the cornerstone for patients without red flag symptoms, as recommended by the most recent and highest quality study 1.

Key Considerations

• The clinical presentation should guide the investigation, with a focus on identifying red flag symptoms that may indicate a secondary cause of headache.
• A thorough clinical assessment, including a detailed history and physical examination, is essential for diagnosing primary headache disorders such as migraine or tension-type headaches.
• A headache diary can help document patterns, triggers, and response to treatments, and is a useful tool for managing chronic headaches.

Investigations

• Neuroimaging, such as brain MRI or CT scans, may be necessary for patients with red flag symptoms or abnormal neurological examination findings.
• Laboratory tests, such as complete blood count, metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and C-reactive protein, may be ordered to rule out systemic causes of headache.
• Specialized tests, such as temporal artery biopsy or sleep studies, may be warranted in specific cases.

Prioritization of Investigations

• The most recent and highest quality study 1 recommends a stepped approach to investigation, with a focus on thorough clinical assessment and headache diary for patients without red flag symptoms.
• Neuroimaging and laboratory tests should be reserved for patients with red flag symptoms or abnormal neurological examination findings.

Conclusion is not allowed, so the response will continue with more details

Additional Considerations

• The study 1 also highlights the importance of patient education and empowerment in managing chronic headaches.
• A multidisciplinary approach, including primary care physicians, specialists, and other healthcare professionals, may be necessary for optimal management of chronic headaches.
• The use of evidence-based treatments, such as prophylactic prescription pharmacologic agents and nonpharmacologic interventions, should be guided by the most recent and highest quality evidence 1.

From the Research

Investigations for Chronic Headaches

• The following investigations are recommended for patients presenting with chronic headaches:
  • Magnetic resonance imaging (MRI) of the head if a red flag for a secondary cause of headache is present 2
  • A thorough headache history to determine whether the headache is a primary or secondary headache disorder 3, 4, 5
  • A complete neurological examination to evaluate for symptoms or signs that suggest an urgent medical problem 3, 5
  • Consideration of neuroimaging in specific limited situations, such as an abnormal neurological examination or presence of red flags 5, 6
  • Serum or spinal fluid analysis if indicated 5

Red Flags for Secondary Headache Disorders

• Red flags for secondary headache disorders include:
  • Abrupt onset of headache
  • Neurologic signs
  • Age 50 years and older
  • Presence of cancer or immunosuppression
  • Provocation by physical activities or postural changes 3, 4, 5

Neuroimaging for Chronic Headaches

• The effectiveness of computed tomography (CT) and MRI scans in the evaluation of persons with chronic headache and a normal neurological examination is limited 6
• The pre-test probability of significant intracranial abnormalities in persons with chronic headaches is low, approximately 0.9% 6
• Clinical findings from the history and physical may be used as screening tests to predict abnormalities on neuroimaging, with certain clinical variables having statistically significant positive and negative likelihood ratios 6