Get answers to your Pediatric Headache and Hospitalist questions.
Diagnosing the cause of persistent daily headache is difficult, even for expert doctors. Studies report that people who visit the emergency room with disabling headache are often misdiagnosed as tension-type headaches instead of migraines. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.
Extensive testing may be advised for anyone with a chronic, daily headache. Tracking times of medications, withdrawal, and headache, using the headache diary, is usually very helpful in diagnosis.
According to the International Headache Society, a diagnosis of tension-type headache is suggested by the following symptoms:
In episodic tension-type headaches:
In chronic tension-type headaches:
About a third of persistent headaches are the result of the rebound effect caused by the overuse of headache medications (formerly called rebound headaches).
Usually in such cases, medications have been taken on an ongoing basis for more than 3 days each week. If patients stop taking these drugs, the headaches come back. The patient then starts taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Even after successful medication withdrawal, relapse is common, particularly with drugs that contain caffeine, so doctors should check for this type of headache even in patients who have previously been treated.
Medications implicated in medication-overuse headache include barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.) Simple painkillers, such as aspirin or ibuprofen, are less likely causes of medication-overuse headaches.
Migraines and tension headaches have some similar characteristics, but also some important differences:
[For more information, see In-Depth Report #97: Migraine headaches.]
For an accurate diagnosis, the patient should describe the following:
The patient should also report any other conditions that might be associated with headache, such as any:
The doctor will also need the patient's general medical and family history, particularly concerning headaches or other neurological diseases.
The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches, and to help the doctor differentiate between migraine and tension-type headache. Be sure to include all events preceding an attack. Often two or more triggers interact to produce a headache.
Researchers are investigating triggers of headaches to determine if certain ones are more likely to set off different primary headaches. In general, however, the same stimuli seem to trigger any of the primary headaches, although people with migraines may be more sensitive to some of them (weather, certain smells, light, and smoke) than people with tension headaches.
Tracking medications is an important way of identifying medication-overuse headache or transformed migraine.
Be sure to attempt to define the intensity of the headache. There are different scoring symptoms available that help communicate the severity of the pain to the doctor. For instance, the following is a number system that can be helpful:
1 = Mild, barely noticeable
2 = Noticeable, but does not interfere with work/activities
3 = Distracts from work/activities
4 = Makes work/activities very difficult
5 = Incapacitating
In order to diagnose a chronic headache, the doctor will examine the head and neck to check for muscle tenderness. The doctor may also perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, sensation, and mental function. The doctor may also recommend an eye examination.
Imaging tests of the brain may be recommended under the following circumstances:
Imaging tests may also be recommended for:
The following tests may be used:
Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. (It should again be emphasized that a headache is not a common symptom of a brain tumor.) People with existing chronic headaches, however, might miss a more serious condition believing it to be one of their usual headaches. Such patients should immediately call a doctor if the quality of a headache or accompanying symptoms has changed. Everyone should call a doctor for any of the following symptoms:
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