How Headaches Are Diagnosed

Diagnosis of a headache takes several things into account, including when episodes occur, what symptoms you experience, how they respond to treatments you've tried, your overall health profile, and more. By performing a detailed history and physical exam, and perhaps some testing, your physician will work to identify what type of headache you are experiencing or, if a headache disorder is not at the root of your pain, what other condition may be causing your symptoms.

Your doctor will do a physical examination, which will give details about your blood pressure and cardiorespiratory functions. A neurological examination will evaluate your sensory responses, muscle and nerve function, and coordination and balance.

Your healthcare provider will also make note of your personal and family medical history, any medications you are taking, and your lifestyle habits (e.g., caffeine intake, alcohol use, smoking).

When evaluating you, your doctor will first likely ask you several specific questions about your headache. These questions include:

• Location: Where is the pain located?
• Onset: Was the onset of your head pain rapid or gradual?
• Duration: How long has the pain been going on for? Is the pain constant or intermittent?
• Character: How would you describe your headache? (e.g., throbbing, aching, burning, or sharp)
• Severity: How significant is your pain on a scale of 1 to 10? Would you describe your headache as mild, moderate, or severe? Is this the worst headache of your life?
• Radiation: Does the pain radiate? If so, where?
• Exacerbating or alleviating factors: What makes the pain better or worse?
• Associations: Are there other symptoms associated with your headache? (e.g., nausea, vomiting, visual changes)

Your doctor may also use responses to the POUND mnemonic or the ID Migraine Questionnaire.

Based on this information, your healthcare provider can decide whether or not your headache is a type of primary headache disorder or possibly due to something else.

There aren't lab tests that are specific for diagnosing primary headache disorders. You may have blood and urine tests to assess your general health and rule out the causes of secondary headaches, such as infection, dehydration, diabetes, and thyroid disorders.

If an infection of the brain or spinal cord is suspected, your doctor may do a spinal tap to assess the pressure of the fluid and analyze it for infectious agents.

An electroencephalogram (EEG) may be performed if your headaches have accompanied any symptoms of seizures.

Although they are not a routine part of a headache workup, your doctor may order imaging tests if you have symptoms that point to a structural cause for your headaches. This may be recommended if you have headaches almost every day or if your doctor thinks you may have sinus problems.

Imaging procedures might include X-rays, computed tomography (CT) scan, or magnetic resonance imaging (MRI).

Certain distinct characteristics of the three main headache types—tension-type, cluster, and migraine—help doctors determine exactly what type of primary headache concern is at play, one is suspected.

Tension-type headaches are usually bilateral, non-pulsating, are not exacerbated by routine physical activity and are not associated with nausea or auras. They can be associated with photophobia or phonophobia (sensitivity to light and sound, respectively).

(Note that, according to the criteria created by International Classification of Headache Disorders, tension-type headaches can only be associated with either photophobia or phonophobia—not both.)

Frequent tension-type headaches often coexist with migraine without aura, so maintaining a headache diary is critical, as a treatment for these conditions is distinct.

A cluster headache—also known as a “suicide headache” due to its severe, debilitating intensity—plagues men more than women.

These headaches occur in clusters or periods of time that typically last from one week to one year followed by pain-free periods of at least one month, though there are exceptions.

During an episodic cluster headache, the sufferer can experience multiple attacks, typically for up to eight days. Some individuals suffer from chronic cluster headaches in which a headache period will either last for more than one year straight or pain-free periods will occur but will be less than one month.

In addition to the autonomic symptoms mentioned above, cluster headaches may also cause eyelid swelling, forehead, and facial sweating, miosis and/or ptosis, and agitation and/or restlessness.

Migraines are more than just headaches. A migraine is a common, neurologic condition that may or may not be associated with a migraine aura, a disturbance that classically causes visual symptoms, but also may include other neurologic symptoms, like sensory or speech alterations.

Your doctor will consider whether there might be an infectious cause for a headache. You might have a headache with many types of viral, bacterial, fungal, or parasitic infections. Of special concern are infections of the brain or spinal cord.

A stroke, hemorrhage, or blood clot in the brain is a serious condition that might present with a headache, and your doctor will want to ensure one isn't missed, if present. High blood pressure or recent trauma might lead to these problems.

There may be a structural cause for the headache, such as a tumor, abscess, or buildup of fluid in the brain. A headache can also be the result of taking pain medication too often.

When assessing your headache disorder, your doctor will likely ask you a lot about your symptoms to better understand them. It may be a good idea to write down answers to the above questions prior to your visit, so you are best prepared. Try to be thorough and proactive when evaluating your own headaches, so that together you and your doctor can create an effective treatment plan.