What is the appropriate workup for a patient with new onset headache?

From the Guidelines

The workup for a new onset headache should begin with a thorough history and physical examination, applying the ICHD-3 criteria, to identify concerning features that might indicate a serious underlying cause. This approach is supported by the most recent and highest quality study, which emphasizes the importance of taking a careful medical history and using validated diagnostic aids and screening tools, such as headache diaries, the three-item ID-Migraine questionnaire, and the five-item Migraine Screen Questionnaire 1. Key red flags to look out for include sudden onset "thunderclap" headache, headache with fever, headache in patients over 50 years old, neurological deficits, headache worsened by Valsalva maneuvers, or headache in immunocompromised patients.

Basic neurological examination should assess mental status, cranial nerves, motor and sensory function, reflexes, and coordination. Initial diagnostic testing may include complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and C-reactive protein to screen for infection or inflammation. Neuroimaging with CT or MRI is indicated if there are concerning features in the history or examination, as recommended by the 2021 study in Nature Reviews Neurology 1. CT is preferred for acute presentations to rule out hemorrhage, while MRI provides better visualization of brain parenchyma and posterior fossa structures.

Some key points to consider in the workup include:

• Using validated diagnostic aids and screening tools to guide diagnosis and management
• Considering differential diagnoses, including other primary headache disorders and secondary headache disorders
• Using neuroimaging only when a secondary headache disorder is suspected, as recommended by the 2021 study 1
• Tailoring the workup to the individual presentation, with more urgent and extensive evaluation for patients with concerning clinical features. The older study from 2002 1 provides some general guidance on the initial task in managing a patient who presents with migraine headache, but the more recent and higher quality study from 2021 1 provides more specific and detailed recommendations for the workup and management of new onset headache.

From the Research

Diagnostic Approach

The diagnostic approach for a patient with new onset headache involves a thorough history and physical examination to distinguish between primary and secondary headache disorders 2, 3, 4. The history should include questions about the onset, duration, frequency, and characteristics of the headache, as well as any associated symptoms or red flags.

Red Flags

Red flags that warrant further evaluation for a secondary headache include:

• Recent head or neck injury
• New, worse, worsening, or abrupt-onset headache
• Headache brought on by exertion or Valsalva maneuver/cough
• New headache in a patient over the age of 50
• Neurological symptoms and/or abnormal signs
• Systemic symptoms and/or signs
• Secondary risk factors such as a history of cancer or human immunodeficiency virus infection 2, 3, 4

Diagnostic Investigations

Diagnostic investigations may include:

• Neuroimaging (e.g. noncontrast computed tomography of the head, magnetic resonance imaging of the brain) to exclude acute intracranial hemorrhage or mass effect 2, 3
• Cerebrospinal fluid examination to rule out subarachnoid hemorrhage 2, 3
• Blood testing in specific situations 2

Primary Headache Disorders

Primary headache disorders, such as tension-type headache and migraine, can be diagnosed based on clinical features and do not typically require neuroimaging 3, 5. The SNNOOP10 mnemonic can be used to detect life-threatening secondary causes of headaches 3.

Treatment

Treatment of headaches depends on the underlying cause and may include symptomatic pharmacotherapy, such as over-the-counter analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and triptans 6. Preventive treatment may be indicated for frequent headaches, and behavioral strategies should be part of any comprehensive headache management plan 5.

Key Considerations

Key considerations in the workup of a patient with new onset headache include:

• A thorough history and physical examination to identify red flags and distinguish between primary and secondary headache disorders
• Careful attention to avoiding too frequent administration of acute therapy to avoid medication overuse headaches
• Avoidance of opioids for acute treatment of headache
• Consideration of preventive treatment for frequent headaches
• Use of behavioral strategies as part of a comprehensive headache management plan 2, 3, 4, 5