Perhaps the most important aspect of headache management is making the correct diagnosis. Treating the headache with analgesics (pain-killers) without making the specific diagnosis is all too common and is likely to lead to a dissatisfied patient or worse. History The most important aspect of headache diagnosis is the history (complete story of the headaches). Unfortunately, in the times of managed care and the pressure on physicians to spend less time with each patient, taking an adequate history is difficult in the time allotted. But there is no diagnostic test or procedure that will substitute for a good history. Some important elements that must be determined are: Speed of onset and circumstances surrounding onset. Character of the pain (constant, throbbing, stabbing, burning, etc.) Severity of pain (measured by whether patient had to go to bed, stop activities, etc.) Location of pain (frontal, occipital (back of head), unilateral (one side of head only), etc.) Accompanying symptoms (nausea & vomiting, photophobia, stiff neck, fever etc.) Time course (progression of symptoms, frequency of attacks, duration of attacks, age at onset, etc.) Aggravating factors (lights, noise, exercise, cough, sneeze, stress, chewing, alcohol, birth control pills, etc.) Relieving factors (drugs, darkness, sleep, rest, lying down, etc.) Previous treatments (drugs, dietary changes) and results. Previous head injuries. Family history (who else in the family has/had headaches. Other illnesses and medications prescribed or over-the-counter. Habits of sleep, work, diet, use of alcohol, drugs, etc. One is especially looking for progressive symptoms, abrupt onset, changes in level of consciousness or cognition, that may indicate a seriously underlying problem. Some patients will have more than one type of headache, and so the information about each type of headache has to be obtained. Patients can help their physicians by going over this information and organizing their thoughts ahead of their visit so that all of this information is given to the physician. Physical Examination Headache patients then need to have a physical examination, directed by the history above, oriented toward looking for signs of disease that might cause headaches. This examination is usually normal in most headache patients, since migraine, the most common cause of severe headache, rarely produces any signs detectable on physical examination, although migraine with aura (classical migraine) can produce neurologic signs such as loss of visual field, decreased sensation, weakness, cognitive (intellectual) changes, drooping of eyelid and small pupil (Horner's syndrome) during an attack. One is especially looking for focal neurologic signs indicating structural disease of the brain, or signs of infection (fever, rash), or stiff neck, indicating meningeal irritation (meningitis or blood in the subarachnoid space) and signs of high pressure inside the head (papilledema). The head and neck examination (including eyes) is especially important. Diagnostic testing Depending on the circumstances, it may be desirable to obtain laboratory tests such as a complete blood count (may indicate infection or anemia), a sedimentation rate (infection or temporal arteritis), thyroid tests, kidney function evaluation (overuse of analgesics). Many if not most headache patients will receive imaging studies. These are especially important when the history and/or examination indicate the possibility of a structural lesion such as a brain tumor,abscess,hemorrhage, or an aneurism, or hydrocephalus. CT scanning is most helpful to detect bleeding into the head. MRI scanning does not require radiation and is more sensitive for tumors, subtle changes in brain structure, Chiari malformations, and inflammatory disease. MRI costs more, however, and the patient spends a longer time and most MRI machines are confining and patients with claustrophobia may have difficulty. There are now available "open" MRIs that don't have this latter problem. MRA angiography can also be done with the MRI, although it is not as good as standard invasive angiography for the detection of aneurysms. Lumbar puncture (spinal tap) may be needed in cases of suspected infection (meningitis) or increased pressure in the spinal fluid causing headache. CT or MRI should be done first, usually, to avoid tapping a patient with an intracranial mass lesion (tumor, abscess, etc.). Patients with histories suggesting sinus headache or TMJ problems may need further x-rays or evaluations for these problems. Diagnostic nerve blocks (for example, the occipital nerve) with local anesthesia may be diagnostic as well as therapeutic. Serious conditions causing headache and how to rule them out Bleeding inside the head Subarachnoid hemorrhage Rupture of an aneurysm (blowout of an artery) or bleeding from a vascular malformation causes increased pressure around the brain and a sudden, severe headache, often followed by a stupor or coma. Nausea and vomiting often occur, as well as stiff neck. Unfortunately, many acute migraines are similar to this, and unless the patient has a clear history of previous migraines, they need to be investigated for hemorrhage. A CT scan without contrast will usually show the presence of blood around the brain, but a lumbar puncture may be necessary to rule out small bleeds. Parenchymal brain hemorrhage Sudden bleeding into the brain itself can also cause a sudden headache. Almost always, there will be signs on neurologic examination, such as weakness, clumsiness, double vision, etc. If the blood ruptures into a ventricle, the same signs as subarachnoid hemorrhage may be present. Most of these patients have hypertension (high blood pressure). CT of the brain is very sensitive in detecting blood in the brain. Subdural or epidural hematoma Bleeding between the meninges (membranes around the brain) and the brain (subdural) or between the meninges and the skull (epidural) can cause severe headache. The headache comes on more rapidly with epidural than subdural hematoma. These are usually caused by a severe blow to the head. Babies and the elderly are more susceptible to subdurals, and it may not take as severe an injury to cause one in these groups. Imaging of the brain will generally rule these out. Brain tumor or abscess Both benign and malignant tumors of the brain and walled-off infections (abscesses) can cause headaches. The headache is usually mild to moderate, present much of the time, and slowly gets worse as the tumor or abscess enlarges. By the time the headache is severe, the patient usually has clear neurologic impairment. Such headaches are usually worse lying down and are not usually localized to any one spot in the head. Migraine patients often come to the doctor worried about a brain tumor and it is important to reassure them they don't have one after they have been examined and investigated. Tumors large enough to cause headaches almost always produce signs on examination or epileptic seizures, and are easy to spot on CT or MRI scanning. Meningitis Infections of the coverings of the brain usually present with headache evolving over hours to days, stiff neck, photophobia (light hurts the eyes), and often nausea, vomiting, fevers, and drowsiness or even coma. CT or MRI with contrast often shows enhancement of the meninges. Lumbar puncture should be done to obtain fluid for analysis. Inflammatory cells are found in the fluid. The nature of the inflammatory response is a good clue as to whether the infecting organism is viral, bacterial, or fungal, and often cultures can be grown from the fluid. Antibiotics are given where appropriate. Time is of the essence in diagnosing meningitis, since some organisms grow rapidly and death may ensure in a matter of hours.