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Headache - assessment - Management
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How should I assess someone presenting with a headache?
- Consider the possibility that more than one type of headache disorder is present.
- Assess for symptoms of:
- Examine for signs of secondary causes of headache. This examination should include at least:
- Measurement of blood pressure.
- Palpation of the temporal arteries, if the person is more than 50 years of age.
- A neurological examination, including fundoscopy for papilloedema.
- If the cause of the headache can not be diagnosed, consider:
- Asking the person to record a headache diary, and reviewing this in a few weeks.
- Diaries help to obtain an accurate description of symptoms necessary for diagnosis and may be particularly useful when symptoms are difficult to interpret due more than one type of headache disorder occurring in the same person.
- The diary should record each episode of headache, its severity, duration, any triggers (including postural changes suggestive of raised intracranial pressure), associated symptoms, and use of analgesia and caffeinated drinks.
- Referral for specialist assessment.
Basis for recommendation
Stepped approach to diagnosis
- This approach to diagnosis is based on:
Headache diary
- The recommendation to consider the use of a headache diary is based on expert opinion [SIGN, 2008].
Referral for specialist assessment
- Referral for specialist assessment is recommended when a diagnosis can not be reached. This may occur with:
- Headache disorders that may present with difficult to interpret symptoms.
- Rare headache disorders not covered by this assessment.
What serious secondary causes for headache must I exclude?
- Suspect a serious cause if a headache:
- Follows trauma to the head and the headache is progressive, and especially if it is associated with impaired consciousness and/or a focal neurological deficit. If this occurs, suspect an epidural or subdural haematoma.
- Is sudden, with a rapid time to peak headache intensity (that is, from a few seconds to 5 minutes). If this occurs, suspect a subarachnoid haemorrhage.
- Develops simultaneously with a sudden onset of neurological impairment of speech, sensation, power, or consciousness, especially if the impairment lasts longer than 1 hour. If this occurs, suspect a transient ischaemic attack or stroke (including subarachnoid haemorrhage).
- Is associated with fever and impaired consciousness, neck stiffness, or photophobia. If this occurs, suspect an intracranial infection (such as meningitis or encephalitis).
- Is associated with tenderness over the temporal artery in a person older than 50 years of age. If this occurs, suspect giant cell arteritis.
- Is associated with features indicating a high risk of a space occupying lesion, including people with:
- A new headache accompanied by features suggestive of raised intracranial pressure, including papilloedema, vomiting, posture-related headache, or headache waking them from sleep (unless it is clearly cluster headache).
- A new headache accompanied by focal neurological symptoms, or non-focal neurological symptoms such as blackout, change in personality or memory.
- An unexplained headache that becomes progressively severe.
- An unexplained headache in anyone previously diagnosed with cancer.
- A new-onset of epileptic seizures.
- Is associated with features indicating a moderate risk of a space occupying lesion, including people with:
- A new headache, when a diagnostic headache pattern has not emerged after 8 weeks.
- A new headache, in a person older than 50 years of age.
- Is associated with severe unilateral eye pain, red eye, fixed and dilated pupil, hazy cornea, or diminished vision. If this occurs, suspect acute glaucoma.
- Is associated with nausea and impaired concentration in a person exposed to a potential carbon monoxide source, including smoke, engine exhausts, or gases from gas or solid fuel appliances retained in an enclosed space. Severe poisoning can cause impaired consciousness, chest pain, and a wide range of neurological deficits.
- If symptoms of a serious cause of headache are excluded assess for medication-overuse and other secondary causes of headache.
Basis for recommendation
Features of serious causes of headache
Features indicating high or moderate risk of a space-occupying lesion
- These recommendations are based on expert opinion informed by limited evidence. They are adapted from Referral guidelines for suspected cancer [NICE, 2005] and Imaging patients with suspected brain tumour: guidance for primary care [Kernick et al, 2008].
How do I diagnose medication overuse and other secondary causes of headache?
- Exclude symptoms of serious secondary causes of headache, before considering other secondary causes.
- Suspect medication-overuse headache (MOH) in people with tension-type headache (TTH) or migraine, when they experience a chronic headache (headache on more than 15 days a month) that develops or worsens with frequent use of any pain relief medication.
- MOH can occur with frequent use of any symptomatic treatment for acute headache. Typically, it develops with drug treatment of episodic migraine or TTH, but may occur in people with migraine or TTH who take analgesics for other painful conditions.
- The symptoms of MOH resemble chronic TTH or chronic migraine; people overusing triptans are more likely to have migraine-like symptoms.
- MOH resolves following withdrawal of symptomatic treatment. This may result in complete resolution of the headache or leave the person with their original episodic migraine or TTH.
- Suspect other secondary causes when headache is associated with:
- Caffeine withdrawal, in people consuming frequent caffeinated drinks such as tea, coffee, or colas.
- Medications known to cause headache, such as nitrates and calcium channel blockers.
- Pain that is localized to structures in the head and neck (such as the eyes, ears, sinuses, temporomandibular joint, teeth, or neck) indicative of conditions such as acute otitis media and sinusitis.
- Fever or general malaise and evidence of systemic infection.
- Head or facial pain in the area of a herpetic eruption.
- If symptoms of a secondary cause of headache have been excluded, consider a diagnosis of tension-type headache or migraine (common primary causes of headache).
Basis for recommendation
Approach to diagnosis
Diagnosis of medication-overuse headache
How do I diagnose tension-type headache and migraine?
- Exclude symptoms of serious secondary causes and other secondary causes of headache before considering a diagnosis of tension-type headache or migraine.
- Suspect migraine in people who present with a pattern of recurrent episodes of severe disabling headache associated with nausea and sensitivity to light, who have a normal neurological examination.
- Diagnose migraine without aura when there are recurrent episodes of headache, lasting between 4 hours and 3 days, that are characteristically:
- Unilateral.
- Pulsating in character.
- Moderate-to-severe in intensity.
- Aggravated by routine physical activity.
- Associated with either nausea or vomiting, or photophobia and phonophobia, or both.
- Diagnose migraine with aura when typical symptoms of migraine are preceded by the onset of an aura consisting of visual or sensory symptoms or dysphasia. Symptoms develop gradually and are fully reversed within 1 hour.
- Visual symptoms include flickering lights, spots, lines, or loss of vision.
- Sensory symptoms include pins and needles, or numbness.
- Suspect tension-type headache if the person presents with bilateral headache that is non-disabling and neurological examination is normal.
- Diagnose tension-type headache when there are recurrent episodes of headache, lasting between 30 minutes and 7 days, that are characteristically:
- Bilateral.
- Pressing or tightening in character.
- Mild-to-moderate in intensity.
- Not aggravated by routine physical activity.
- Not associated with nausea or vomiting.
- Sometimes associated with photophobia or phonophobia, but not both.
Basis for recommendation
When to suspect migraine
- This recommendation is based on evidence on the sensitivity and specificity of a simple screening tool for migraine [Lipton et al, 2003].
- A self-assessment questionnaire (that screened for migraine based on headache severity, sensitivity to light, and nausea) was completed by 451 people presenting with headache in primary care.
- This was compared with a gold-standard assessment carried out by a headache expert using the International classification of headache disorders diagnostic criteria for migraine.
- Screening for migraine using the self-assessment questionnaire achieved:
- A sensitivity of 0.81 (95% CI 0.77 to 0.85).
- A specificity of 0.75 (95% CI 0.64 to 0.84).
When to suspect tension-type headache
- This recommendation is based on expert opinion [SIGN, 2008].
Diagnostic features of migraine and tension-type headache
How do I diagnose the less common causes of headache?
- Exclude symptoms of serious secondary causes and other secondary causes of headache, and tension-type headache and migraine, before considering less common causes of headache. Ask about:
- Duration, frequency, and any diurnal pattern.
- Location — unilateral, bilateral, or localized to areas of the face or scalp.
- Intensity and character.
- Association with ipsilateral autonomic features, including:
- Conjunctival injection or lacrimation.
- Eyelid oedema.
- Miosis or ptosis.
- Nasal congestion or rhinorrhoea.
- Forehead and facial sweating.
- Episodic unilateral facial pain (in areas supplied by one or more divisions of the trigeminal nerve), lasting a few seconds to 2 minutes, is diagnosed as:
- Trigeminal neuralgia when it is sharp, stabbing, intense in character, and triggered by a trivial stimulus, such as light touch. It usually affects the cheek and chin.
- Episodic unilateral headache that is severe and orbital, supraorbital, or temporal is diagnosed as:
- Cluster headache when:
- Severe pain lasts between 15 minutes and 3 hours, and is associated with intense restlessness and agitation, and may be triggered within 90 minutes of drinking alcohol.
- Episodes occur between one every other day and eight-times daily, often waking the person at night.
- At least five episodes of pain have occurred.
- The headaches are associated with at least one ipsilateral autonomic feature.
- Paroxysmal hemicrania when:
- Pain lasts between 2 minutes and 30 minutes.
- Episodes occur more than five times a day more than half of the time, although periods with lower frequency may occur.
- At least 20 episodes of pain have occurred.
- Pain responds completely to therapeutic doses of indometacin.
- Associated with at least one ipsilateral autonomic feature.
- Persistent unilateral headache is diagnosed as:
- Hemicrania continua when it is a moderate-intensity headache with severe exacerbations and is:
- Associated with at least one ipsilateral autonomic feature, other than facial sweating or eyelid oedema.
- Unremitting, and has lasted for more than 3 months.
- Completely responsive to therapeutic doses of indometacin.
Basis for recommendation
How do I manage a person with headache?
- If a serious secondary cause of headache is suspected:
- Arrange immediate admission for people with a headache that is suspected to be secondary to:
- Epidural or subdural haematoma.
- Stroke, including subarachnoid haemorrhage.
- Intracranial infection, such as meningitis or encephalitis.
- Acute glaucoma.
- A suspected space occupying lesion associated with rapidly progressive neurological signs or seizures.
- For people with features indicating a higher risk for a space-occupying lesion, arrange urgent investigation either by:
- Urgent referral to a specialist (to be seen within 14 days), or
- Direct referral for brain imaging from primary care, where this is available.
- For people with features indicating a moderately increased risk for a space-occupying lesion, monitor carefully and have a low threshold for investigation.
- Manage people with headaches secondary to suspected:
- If the headache is thought to be secondary to other underlying causes, manage the underlying cause. CKS topics are available on the management of:
- If a primary headache disorder or trigeminal neuralgia is suspected, see the CKS topics on:
- If paroxysmal hemicrania or hemicrania continua is suspected, treat with indometacin and refer for specialist management.
- If there is no clear diagnosis following assessment, refer for specialist assessment of the cause.
Basis for recommendation
Features indicating a serious cause for headache requiring emergency admission
- Emergency admission for people with a serious cause for headache is based on expert opinion [SIGN, 2008].
Features indicating high or moderate risk of a space-occupying lesion
- The management of people based on the risk of a space-occupying lesion is based on Imaging patients with suspected brain tumour: guidance for primary care [Kernick et al, 2008]. This guidance is based on a review of the evidence, by 13 experts, of the predictive value of risk factors and clinical features for space-occupying lesions.
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