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

From the Guidelines

A comprehensive headache workup should begin with a detailed history and physical examination to identify the type of headache and potential causes, as recommended by the American Academy of Neurology and the U.S. Headache Consortium 1. When evaluating a patient with a headache, it is essential to start by asking about headache characteristics, including location, quality, severity, duration, frequency, and associated symptoms like nausea, vomiting, photophobia, or phonophobia, as outlined in the International Headache Society Classification of Headaches 1.

• Inquire about triggers, alleviating factors, and timing to better understand the patient's condition.
• The physical examination should include vital signs, neurological assessment, and examination of the head, neck, and sinuses. For primary headaches like migraines or tension headaches, no further testing may be needed, according to the U.S. Headache Consortium guidelines 1.
• However, for secondary headaches or concerning features (sudden onset, worst headache of life, neurological deficits, fever, immunocompromised state, age over 50, or change in pattern), consider neuroimaging with CT or MRI, as suggested by the American Academy of Neurology 1. Some key points to consider when evaluating a patient with a headache include:
• The American Academy of Neurology suggests that neuroimaging should be considered only in patients with migraine who have atypical headache patterns or neurologic signs 1.
• The U.S. Headache Consortium guidelines do not recommend neuroimaging if the patient is not at higher risk of a significant abnormality than the general population or if the results of the study would not change the management of the headache 1.
• Symptoms that increase the odds of positive neuroimaging results include rapidly increasing frequency of headache, a history of uncoordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep, as outlined in the U.S. Headache Consortium guidelines 1. Laboratory tests may include complete blood count, metabolic panel, ESR/CRP for inflammatory conditions, and lumbar puncture if meningitis or subarachnoid hemorrhage is suspected, as recommended by the American Academy of Neurology 1.
• Additional testing like EEG or sleep studies may be warranted based on clinical presentation, as suggested by the U.S. Headache Consortium guidelines 1. This systematic approach helps differentiate between benign primary headaches and potentially life-threatening secondary causes, ensuring appropriate management and treatment, as recommended by the American Academy of Neurology and the U.S. Headache Consortium 1.

From the Research

Headache Workup

• The diagnosis of headache is typically made by a careful history and physical examination, with diagnostic testing indicated when in doubt 2, 3.
• Certain historical and examination findings increase the likelihood of a secondary headache disorder and the need for diagnostic testing, including:
  • Recent head or neck injury
  • New, worse, worsening, or abrupt onset headache
  • Headache brought on by Valsalva maneuver or cough
  • Headache brought on by exertion
  • Headache associated with sexual activity
  • Pregnancy
  • Headache in the patient over the age of ~50
  • Neurologic findings and/or symptoms
  • Systemic signs and/or symptoms
  • Secondary risk factors, such as cancer or human immunodeficiency virus (HIV) infection 2
• Diagnostic studies include:
  • Neuroimaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans
  • Cerebrospinal fluid (CSF) examination
  • Blood tests, which are selected depending on the patient's history and findings 2, 4
• The choice of diagnostic test depends on the patient's history and findings, with MRI being the diagnostic test of choice for most patients, and CT being used in the setting of trauma or abrupt onset of headache 2, 4

Red Flags for Secondary Headache Disorders

• Red flags for secondary headache disorders include:
  • Abrupt onset
  • Neurologic signs
  • Age 50 years and older
  • Presence of cancer or immunosuppression
  • Provocation by physical activities or postural changes 3, 5
• The presence of these red flags suggests the need for further evaluation and diagnostic testing to rule out secondary headache disorders 3, 5

Treatment of Headache Disorders

• The treatment of headache disorders depends on the underlying cause, with primary headache disorders being treated with analgesics, nonsteroidal anti-inflammatory drugs, and migraine-specific treatments such as triptans and gepants 6, 5
• Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, and calcitonin gene-related peptide monoclonal antibodies, may be used to reduce the frequency of headaches 6, 5