Abstract
The complaint of headache may be associated with a number of medical disorders but is most often a symptom of a primary headache disorder. An astute clinician must recognize red flags in the medical history and examination that will point to a more ominous and potential life-threatening secondary headache. Although most patients can be accurately diagnosed by history and physical alone, additional neuroimaging and laboratory testing may be appropriate in select patients. Once secondary headaches have been excluded, determining which primary headache to classify the patient will assist in choosing the appropriate therapy. The most common primary headache disorders seen in clinical practice include migraine, tension-type headache, and cluster headache.
Keywords
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Jensen R, Stovner LJ. Epidemiology and comorbidity of headache. Lancet Neurol. 2008;7(4):354–61. doi:10.1016/S1474-4422(08)70062-0.
Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in the general population—a prevalence study. J Clin Epidemiol. 1991;44(11):1147–57.
Headache Classification Committee of the International Headache Society (IHS). The international headache classification of headache disorder (3rd ed, Beta Version). Cephalalgia. 2013;33(9):629–808. doi:10.1177/0333102413485658.
Tepper SJ, Dahlöf CG, Dowson A, Newman L, Mansbach H, Jones M, et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache. 2004;44(9):856–64.
Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American migraine study II. Headache. 2001;41(7):646–57.
Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800. doi: 10.1016/S0140-6736(15)60692-4.
Goldberg LD. The cost of migraine and its treatment. Am J Manag Care. 2005;11(2 Suppl):S62–7.
Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of population based studies. Cephalalgia. 2008;28(6):614–8. doi:10.1111/j.1468-2982.2008.01592.
Favier I, van Vliet JA, Roon KI, Witteveen RJ, Verschuuren JJ, Ferrari MD, et al. Trigeminal autonomic cephalalgias due to structural lesions: a review of 31 cases. Arch Neurol. 2007;64(1):25–31.
de Coo IF, Wilbrink LA, Haan J. Symptomatic trigeminal autonomic cephalalgias. Curr Pain Headache Rep. 2015;19(8):39. doi:10.1007/s11916-015-0514-z.
Goldstein JN, Camargo CAJR, Pelletier AJ, Edlow JA. Headache in the United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalgia. 2006;26(6):684–90.
Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Ther Adv Neurol Disord. 2013;6(6):369–74. doi:10.1177/1756285613489765.
Gofshteyn JS, Stephenson DJ. Diagnosis and management of childhood headache. Curr Probl Pediatr Adolesc Health Care. 2016;46(2):36–51. doi:10.1016/j.cppeds.2015.11.003.
Hershey AD. Pediatric headache. Continuum (Minneap Minn). 2015;21(4 Headache):1132–45. doi:10.1212/CON.0000000000000197.
Ducros A, Bousser MG. Thunderclap headache. BMJ. 2013;346:e8557. doi:10.1136/bmj.e8557.
Schwedt TJ. Thunderclap headache. Continuum (Minneap Minn). 2015;21(4 Headache):1058–71. doi:10.1212/CON.0000000000000201.
Schievink WI. Spontaneous spinal cerebrospinal fluid leans and intracranial hypotension. JAMA. 2006;295(19):2286–96.
Lipton RB. Risk factors for and management of medication-overuse headache. Continuum (Minneap Minn). Continuum (Minneap Minn). 2015;21(4 Headache):1118–31. doi:10.1212/CON.0000000000000216.
Bigal ME, Serrano D, Buse D, Scher A, Stewart WF, Lipton RB. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48(8):1157–68. doi:10.1111/j.1526-4610.2008.01217.x.
Diener HC, Holle D, Solbach K, Gaul C. Medication-overuse headache: risk factors, pathophysiology and management. Nat Rev Neurol. 2016;12(10):575–83. doi:10.1038/nrneurol.2016.124.
Eross E, Dodick D, Eross M. The sinus, allergy and migraine study. Headache. 2007;47(2):213–24.
Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache. Arch Intern Med. 2004;164(16):1769–72.
Lai TH, Fuh JL, Wang SJ. Cranial autonomic symptoms in migraine: characteristics and comparison with cluster headache. J Neurol Neurosurg Psychiatry. 2009;80(10):1116–9. doi:10.1136/jnnp.2008.157743.
Mehle ME. What do we know about rhinogenic headache? The otolaryngologist’s challenge. Otolaryngol Clin North Am. 2014;47(2):255–64. doi:10.1016/j.otc.2013.10.006.
Hamilos DL. Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011;128(4):693–707. doi:10.1016/j.jaci.2011.08.004.
Tan BK, Chandra RK, Pollak J, Kato A, Conley DB, Peters AT, et al. Incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis. J Allergy Clin Immunol. 2013;131(5):1350–60. doi:10.1016/j.jaci.2013.02.002.
Dodick DW. Clinical clues and clinical rules; primary versus secondary headache. Adv Stud Med. 2003;2:S550–5.
Dodick DW. Pearls: headache. Semin Neurol. 2010;30(1):74–81. doi:10.1055/s-0029-1245000.
Evans RW. Diagnostic testing for headache. Med Clin North Am. 2001;85(4):865–85.
Cady RK. Red flags and comfort signs for ominous secondary headaches. Otolaryngol Clin North Am. 2014;47(2):289–99. doi:10.1016/j.otc.2013.10.010.
Sudlow C. US guidelines on neuroimaging in patients with non-acute headache: a commentary. J Neurol Neurosurg Psychiatry. 2002;72 Suppl 2:ii16–ii18.
Douglas AC, Wippold FJ 2nd, Broderick DF, Aiken AH, Amin-Hanjani S, Brown DC, et al. ACR appropriateness criteria headache. J Am Coll Radiol. 2014;11(7):657–67. doi:10.1016/j.jacr.2014.03.024.
Frishberg BM, Rosenberg JH, Matchar DB, McCrory DC, Pietrzak MP, Rozen TD, et al. Evidence based guidelines in the primary care setting: neuroimaging in patients with non-acute headache. St Paul, MN: US Headache Consortium; 2000. Available from: http://tools.aan.com/professionals/practice/pdfs/gl0088.pdf. Accessed 8 Oct 2016.
Mitsikostas DD, Ashina M, Craven A, Diener HC, Goadsby PJ, Ferrari MD, et al. European headache federation consensus on technical investigation for primary headache disorders. J Headache Pain. 2015;17:5. doi:10.1186/s10194-016-0596-y.
Loder E, Weizenbaum E, Frishberg B, Silberstein S, American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651–9. doi:10.1111/head.12233.
Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: an evidence-based analysis. Ont Health Technol Assess Ser. 2010;10(26):1–57.
Berrington de González A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071–7. doi:10.1001/archinternmed.2009.440.
Feng TY, Han XF, Lang R, Wang F, Wu Q. Subtraction CT angiography for the detection of intracranial aneurysms: a meta-analysis. Exp Ther Med. 2016;11(5):1930–6.
Rustemi O, Alaraj A, Shakur SF, Orning JL, Du X, Aletich VA, et al. Detection of unruptured intracranial aneurysms on noninvasive imaging. Is there still a role for digital subtraction angiography? Surg Neurol Int. 2015;6:175. doi:10.4103/2152-7806.170029.
Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009;193(4):1167–74. doi:10.2214/AJR.08.1688.
Cornelius RS, Martin J, Wippold FJ II, Aiken AH, Angtuaco EJ, Berger KL, et al., American College of Radiology. ACR appropriateness criteria sinonasal disease. J Am Coll Radiol. 2013;10(4):241–6. doi:10.1016/j.jacr.2013.01.001.
Besta R, Shankar YU, Kumar A, Rajasekhar E, Prakash SB. MRI 3D CISS—a novel imaging modality in diagnosing trigeminal neuralgia—a review. J Clin Diagn Res. 2016;10(3):ZE01–3. doi:10.7860/JCDR/2016/14011.7348.
Rhéaume M, Rebello R, Pagnoux C, Carette S, Clements-Baker M, Cohen-Hallaleh V, et al. High-resolution magnetic resonance imaging of scalp arteries for the diagnosis of giant cell arteritis: results of a prospective cohort study. Arthritis Rheumatol 2016. doi:10.1002/art.39824 (Epub ahead of print).
Gil-Gouveia R, Martins IP. Headaches associated with refractive errors: myth or reality? Headache. 2002;42(4):256–62.
Blok KM, Rinkel GJ, Majoie CB, Hendrikse J, Braaksma M, Tijssen CC, et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology. 2015;84(19):1927–32. doi:10.1212/WNL.0000000000001562.
van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain. 2001;124(Pt 2):249–78.
Griffiths MJ, Chow E, Panting MD, Ford C, Gama R. Comparison of original (2003) and revised (2008) national guidelines for reporting of cerebrospinal fluid spectrophotometric scanning for suspected subarachnoid haemorrhage against patient outcome. Ann Clin Biochem. 2010;47(Pt 4):375–7. doi:10.1258/acb.2010.009198.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer International Publishing AG
About this chapter
Cite this chapter
Mays, M. (2017). Differential Diagnosis and Workup of the Headache Patient: Should I Order a Scan?. In: Mehle, M. (eds) Sinus Headache, Migraine, and the Otolaryngologist. Springer, Cham. https://doi.org/10.1007/978-3-319-50376-9_3
Download citation
DOI: https://doi.org/10.1007/978-3-319-50376-9_3
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-50375-2
Online ISBN: 978-3-319-50376-9
eBook Packages: MedicineMedicine (R0)