What is the workup for unilateral headaches?

From the Guidelines

The workup for unilateral headaches should begin with a thorough history and physical examination, focusing on red flag symptoms such as sudden onset, fever, neurological deficits, or onset after age 50, as recommended by recent guidelines 1.

Key Components of the Workup

• Initial testing should include basic blood work (complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein) to rule out systemic causes.
• Neuroimaging is essential, with MRI with and without contrast being preferred over CT scan as it better visualizes posterior fossa lesions, vascular abnormalities, and subtle pathologies.
• If vascular causes are suspected, MR angiography or CT angiography should be considered.
• Lumbar puncture may be necessary if subarachnoid hemorrhage or meningitis is suspected, especially if imaging is normal but clinical suspicion remains high.

Specialized Testing

• For suspected temporal arteritis in older patients, a temporal artery biopsy may be indicated.
• Additional specialized testing might include ophthalmologic examination for ocular causes and dental evaluation if temporomandibular joint dysfunction is suspected.

Diagnosis and Management

• The diagnosis of migraine should be suspected in a person with recurrent moderate to severe headache, particularly if pain is unilateral and/or pulsating, and when the person has accompanying symptoms such as photophobia, phonophobia, nausea and/or vomiting 1.
• The effectiveness of treatment should be evaluated by assessing attack frequency, attack severity, and migraine-related disability, with regular follow-up to review diagnosis and treatment strategies 1.

Considerations in Specific Populations

• In older people, consider the higher risks of secondary headache, comorbidities, and adverse events with older age 1.
• In children and adolescents with migraine, bed rest alone might suffice; if not, use ibuprofen for acute treatment and propranolol, amitriptyline, or topiramate for prevention 1.

From the Research

Unilateral Headaches Workup

The workup for unilateral headaches involves a comprehensive approach to rule out secondary headaches and diagnose primary headache disorders.

• The first step is to take a thorough history and perform a physical examination to identify any red flags that may indicate a secondary headache 2.
• Imaging studies such as cranial magnetic resonance imaging (MRI) or computed tomography (CT) scans may be necessary to rule out secondary headaches caused by intracranial or extracranial structures 3, 2.
• The diagnosis of primary headache disorders such as cluster headache, paroxysmal hemicrania, and SUNCT syndrome can be made based on clinical characteristics and response to treatment 4, 3, 5.
• An algorithm-based approach can be used to diagnose and manage unilateral headaches, starting with the rule-out of secondary headaches and then diagnosing primary headache disorders 2.

Diagnostic Considerations

• Cluster headache is a strictly unilateral headache with cranial autonomic features, and its diagnosis can be made based on clinical characteristics and response to treatment such as oxygen, sumatriptan, and verapamil 4, 5.
• Paroxysmal hemicrania is a unilateral headache that responds to indomethacin, and its diagnosis can be made based on clinical characteristics and response to treatment 3, 5.
• SUNCT syndrome is a rare unilateral headache disorder that can be diagnosed based on clinical characteristics and response to treatment such as lamotrigine, topiramate, and gabapentin 5.

Treatment Options

• The treatment of unilateral headaches depends on the underlying diagnosis, and may include abortive and prophylactic agents such as oxygen, sumatriptan, verapamil, indomethacin, and topiramate 4, 3, 5.
• The use of steroids, ergotamine, and methysergide may also be considered in certain cases 4, 5.
• Surgical procedures may be considered in refractory cases, but require further scientific evaluation 5.