The Kansas CW | Headache work-up: when and why tests are needed

Headache work-up: when and why tests are needed

By Louis Neipris, M.D., Staff Writer, myOptumHealth

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A headache diagnosis doesn't always require a CT scan, MRI or even a blood test. Most headaches are not serious, and don't need expensive imaging tests. In fact, in most cases the history and physical are all your doctor needs to make the diagnosis and a treatment plan. The details of your headache story and a head-to-toe check - including a neurological exam - can help your doctor find the cause of your headache.

What are the types of headaches?

There are two main types of headaches: primary and secondary. Most headaches are "primary." This means the main problem is the headache itself. No other medical problem is causing the headache. Primary headaches are usually:

• Migraine headaches (also called vascular headaches), where pain is focused in one area of the head, often linked to nausea and sensitivity to light.
• Tension headaches, in which muscle tightness causes pain that feels like a "vice grip" around the forehead or base of the neck.
• Cluster headaches, which are repeated headache attacks that occur in clusters.

A secondary type of headache is one related to an underlying medical problem, such as a brain tumor, infection, or bleeding. This type of headache requires urgent medical attention. Imaging and laboratory tests are part of the headache work-up when an underlying medical problem is suspected.

When to seek medical attention for headache

More often than not, a headache is not serious. But if your headaches are severe, recurrent or interfering with your life (missed work, school or social activities), then see your doctor. Other reasons for seeking medical care:

• Your headaches are no longer responding to self-care
• Your headaches change, or are getting worse or more frequent
• You are 50 or older and you are starting to have headaches

Seek emergency medical attention if your headache follows an injury and you also have fever, stiff neck or rash.

Call 9-1-1 right away if your headache has any of the following:

• Sudden onset of very severe pain
• Problems with your vision
• Any confusion or loss of consciousness
• Any numbness of weakness
• Slurred speech
• Trouble with balance or walking
• Seizures
• You would describe the headache as "the worst headache of my life"

The doctor visit for headache

Many headache symptoms fall into a pattern that your doctor can easily recognize. With enough information, your doctor can often diagnose your headaches without expensive testing.

Start the visit with a thorough question and answer session. Your doctor will ask you about your headaches, when they started, how often you have them, where the pain is and about any accompanying symptoms you have during a headache. These could be nausea, light sensitivity, numbness, neck pain or trouble seeing. You'll be asked to describe the pain. Is it stabbing? Dull? Throbbing? On one side or both? Your doctor will also ask about your lifestyle habits, diet, sleep and work environment as well as what brings you relief. Tell your doctor about any family history of headache, recent head injury or surgery, sinus or dental problems and what medications you're taking. Bring in all of your medications or a list of your meds, including doses and how frequently you take them.

Your doctor will do a physical examination, including a full neurological exam. This exam checks for reflexes, muscle strength, sensation, balance and coordination. The results of a neurological exam helps rule out more serious problems or suggests further tests are needed.

Headache tests and why they're done

Tests are usually done to look for or rule out headaches related to a more serious underlying medical problem. Imaging tests are usually not needed for typical migraines. They may be done when the history and physical or neurological exam suggest tumor, infection or bleeding or the cause is otherwise not clear.

• Head CT scan. A CT scan takes multiple images using x-rays and computers to show detail of brain structure. CT without contrast can show bleeding in the brain. CT with contrast can show tumors. A CT scan of the sinuses may also be useful to diagnose chronic sinusitis, which can sometimes be a cause of pain in the face over the sinus areas.
• Brain MRI. MRI uses a powerful electromagnet and a computer to show very detailed images of the brain. An MRI may be used to show structures that CT can not image well, such as the spinal cord. The MRI may be used with an angiogram - x-ray pictures of blood vessels - to show abnormalities in the blood vessels in the base of the brain.
• Lumbar puncture (or spinal tap). In this test, a sample of fluid surrounding the spinal cord is removed using a needle inserted into the lower back. The test may be done if the CT scan is normal and the cause of the headache is still not known. It can help detect problems such as infection or bleeding.

Questions about your headache tests

Make sure you understand the reasoning behind the tests that are ordered for you. Ask your doctor:

• Why do I need the test? Imaging tests are usually done if the history or physical exam cannot uncover the cause of the headache or if a brain tumor, bleeding in the brain or infection is suspected.
• Will the test help to diagnose my headache? Imaging tests are not helpful in diagnosing simple tension, migraine or cluster headaches.
• Will the test change my treatment plan? Ask what results may change the way your headaches are treated.

View the original Headache work-up: when and why tests are needed article on myOptumHealth.com 

SOURCES:

• Morey SS. Practice guidelines: Headache Consortium releases guidelines for use of CT and MRI in migraine work-up. American Family Physician. 2000.

• Clinch CR. Evaluation of acute headaches in adults. American Family Physician. 2001;63(4):685-692. Accessed: 07/20/2009

• American College of Emergency Physicians Clinical Policies Subcommittee. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Annals of Emergency Medicine. 2008;52(4):407-436.

• Gallagher RM. Headache. In: Rakel RE, Bope ET, eds. Rakel: Conn's Current Therapy 2008, 60th ed. Philadelphia, PA: Saunders-Elsevier; 2008.

• Institute for Clinical Systems Improvement. Healthcare guideline: diagnosis and treatment of headache, 9th edition. Accessed: 07/20/2009

• National Institute of Neurological Disorders and Stroke. Headache: hope through research Accessed: 07/20/2009

• Weinstein JM. Headache and Facial Pain. In: Yanoff M, Duker JS, eds. Ophthalmology, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2008.