How to rule in or out the causes of recurring painful headaches?

Diagnosing Causes of Recurring Painful Headaches

The most effective approach to rule in or out causes of recurring painful headaches is through a systematic medical history assessment, focusing on headache characteristics, accompanying symptoms, and red flag features, followed by targeted diagnostic testing only when secondary causes are suspected.

Primary vs. Secondary Headache Differentiation

Initial Assessment for Red Flags

• Evaluate for concerning features that suggest secondary headache requiring urgent attention, including:
  • Recent head or neck trauma 1
  • New, worse, worsening, or abrupt onset headache 1
  • Headache brought on by Valsalva maneuver, cough, or exertion 1
  • Headache associated with sexual activity 1
  • Headache in patients over age 50 1, 2
  • Neurological findings or symptoms 1, 2
  • Systemic signs or symptoms (fever, signs of infection) 2, 3
  • Headache that awakens patient from sleep 2
  • Papilledema with focal neurologic signs 3
  • Impaired consciousness 3

Diagnostic Approach for Primary Headaches

• Collect detailed information about headache characteristics:
  • Age at onset of headache 4
  • Duration of headache episodes 4
  • Frequency of headache episodes 4
  • Pain characteristics (location, quality, severity, aggravating factors, relieving factors) 4
  • Accompanying symptoms (photophobia, phonophobia, nausea, vomiting) 4
  • Aura symptoms (if any) 4
  • History of acute and preventive medication use 4

Diagnostic Tools

• Implement headache diaries to record:
  • Pattern and frequency of headaches 4
  • Accompanying symptoms 4
  • Use of acute medications 4
  • Potential triggers 4
• Consider validated screening instruments:
  • Three-item ID-Migraine questionnaire (evaluates headache-associated nausea, photophobia, and disability) 4
  • Five-item Migraine Screen Questionnaire (evaluates headache frequency, intensity, length, associated symptoms, and disability) 4

Diagnostic Criteria for Common Primary Headaches

Migraine Without Aura

• Recurrent moderate to severe headache with:
  • Unilateral and/or pulsating pain 4
  • Photophobia, phonophobia, nausea and/or vomiting 4
  • Duration of 4-72 hours 5
  • At least five attacks fulfilling these criteria 4

Migraine With Aura

• Recurrent headache with transient focal neurological symptoms that:
  • Develop gradually over ≥5 minutes 4
  • Last 5-60 minutes 4
  • Are followed by headache within 60 minutes 4
  • Include visual, sensory, speech/language, motor, brainstem, or retinal symptoms 4

Chronic Migraine

• Headache (migraine-like or tension-type-like) on ≥15 days/month for >3 months 4
• On ≥8 days/month, headaches have migraine features or respond to migraine-specific medication 4

Medication-Overuse Headache

• Headache on ≥15 days/month in a patient with pre-existing headache disorder 4
• Regular overuse for >3 months of acute headache medications:
  • Non-opioid analgesics on ≥15 days/month 4
  • Other acute medications (triptans, ergots, combination analgesics) on ≥10 days/month 4

Cluster Headache

• Severe unilateral supraorbital or temporal pain lasting 15-180 minutes 5
• Frequency of 1-8 attacks daily 5
• At least one ipsilateral autonomic symptom 5
• Patients typically pace during attacks (unlike migraine) 5

Neuroimaging Guidelines

When Neuroimaging Is Warranted

• Unexplained abnormal findings on neurologic examination 2
• New onset headache in patients over 50 years 2
• Atypical features that don't fit established primary headache patterns 2
• Signs of increased intracranial pressure 4
• Concern for possible tumor 4

When Neuroimaging Is Not Warranted

• Normal neurologic examination 2
• Features consistent with primary headache disorders 2
• Long history of similar headaches without change in pattern 2

Imaging Modality Selection

• MRI is the preferred imaging modality for non-urgent evaluation 4, 3
• CT is typically used for trauma or abrupt onset headache 1, 3
• Additional specialized imaging (MRA, MRV, CTA, CTV) only when specific vascular pathologies are suspected 4

Common Pitfalls and Caveats

• Misdiagnosis of "sinus headache" - approximately 62% of pediatric migraineurs have at least one cranial autonomic symptom (like rhinorrhea) that may be mistaken for sinusitis 4
• Medication overuse headache can complicate diagnosis and treatment - suspect in patients with frequent headaches and regular use of acute medications 6
• Family history of migraine is often under-reported but is an important diagnostic clue 4, 7
• Compliance with headache diaries can be an issue - electronic versions may improve adherence 4
• Primary headache disorders can coexist, complicating diagnosis 8, 9

Diagnostic Algorithm

1. Screen for red flags suggesting secondary headache 1, 3
2. If red flags present: Order appropriate neuroimaging (CT for acute presentations, MRI for non-urgent) 1, 3
3. If no red flags: Assess headache characteristics using detailed history and diagnostic criteria 4
4. Implement headache diary to track patterns and response to treatment 4
5. Consider validated screening tools to support diagnosis 4
6. Evaluate for medication overuse in patients with frequent headaches 4, 6
7. Reassess diagnosis at follow-up using diary information 4