Diagnosis:

Anyone, including children, with recurring or persistent headaches should consult a doctor. There are no blood tests or imaging techniques that can be used to diagnose migraine headaches. A diagnosis will be made on the basis of history and physical exam, and, if necessary, tests may be necessary to rule out other diseases or conditions that may be causing the headaches. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.

Diagnostic Criteria for Migraine

A diagnosis of migraine is usually made on the basis of repeated attacks (at least 5) that meet the following criteria:

• Headache attacks that last 4 - 72 hours
• Headache has at least two of the following characteristics: Location on one side of the head; throbbing pain; moderate or severe pain intensity; pain worsened by normal physical activity (walking, climbing stairs)
• During the headache, the patient experiences one or both of the following characteristics: Nausea or vomiting; extreme sensitivity to light or sound
• The headache cannot be attributed to another disorder

Headache Diary

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, as well as to track the duration and frequency of headache attacks. Some tips include:

• Note all conditions, including any foods eaten, preceding an attack. Often two or more triggers interact to produce a headache. For example, a combination of weather changes and fatigue can make headaches more likely than the presence of just one of these events.
• Keep a migraine record for at least three menstrual cycles. For women, this can help to confirm or refute a diagnosis of menstrual migraine.
• Track medications. This is important for identifying possible rebound headache or transformed migraine.
• Attempt to define the intensity of the headache using a number system, such as:

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

Medical and Personal History

The patient should report any other conditions that might be associated with headache, including but not limited to:

• Any chronic or recent illness and their treatments
• Any injuries, particularly head or back injuries
• Any uncharacteristic dietary changes
• Any current medications or recent withdrawals from any drugs, including over-the-counter or natural remedies
• Any history of caffeine, alcohol, or drug abuse
• Any serious stress, depression, and anxiety

The doctor will also need a general medical and family history of headaches or diseases, such as epilepsy, that may increase their risk. Migraine tends to run in families.

Physical Examination

In order to diagnose a chronic headache, the doctor will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The doctor may ask questions to test short-term memory and related aspects of mental function.

Differentiating Between Migraine and Other Types of Headaches

Differentiating Between Migraines and Tension Headaches. Migraines and tension headaches have some similar characteristics, but also some important differences:

• Migraine pain is throbbing and while tension-type headache pain is usually a steady ache
• Migraine pain may affect only one side of the head while tension-type headache pain typically affects both sides of the head
• Migraine pain, but not tension-type pain, worsens with head movement
• Migraine headaches, but not tension-type headaches, may be accompanied by nausea or vomiting, sensitivity to light and sound, or aura

[For more information, see In-Depth Report #11: Tension-type headache.]

Differentiating Between Migraines and Sinus Headaches. Many primary headaches, including migraine, are misdiagnosed as sinus headaches, causing patients to be treated inappropriately with antibiotics. Nearly 9 in 10 patients who think they have sinus headaches actually have or probably have had a migraine. Sinus headaches occur in the front of the face, usually around the eyes, across the cheeks, or over the forehead. They are usually mild in the morning and increase during the day and are usually accompanied by fever, runny nose, congestion, and general debilitation. It is also possible for patients to have migraines with sinus symptoms.

A real sinus headache is a sign of an acute sinus infection, which responds to treatment with antibiotics. If sinus headches seem to recur, the patient is likely actually experiencing migraines.

Imaging Tests

Imaging tests of the brain may be recommended under the following circumstances.

If the results of the history and physical examination suggest neurologic problems such as:

• Changes in vision
• Muscle weakness
• Fever
• Stiff neck
• Changes in the way someone walks
• Changes in someone's mental status (disorientation)

For patients with headache:

• That wakes them at night
• A sudden or severe headache, or a headache that is the worst headache of someone's life

Imaging tests may also be recommended for:

• Patients with a history of cancer or weakened immune system
• New headaches in adults over 50 years, especially in the elderly. In this age group, it is particularly important to first rule out age-related disorders including stroke, low blood sugar (hypoglycemia), accumulation of fluid within the brain (hydrocephalus), and head injuries (usually from falls).
• Patients with worsening headache or headaches that do not respond to routine treatment.

The following tests may be used:

• A CT (computed tomography) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis.
• X-rays and other tests may also be used if sinusitis is strongly suspected.
• A neck x-ray can reveal arthritis or spinal problems.
• Other imaging tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, positron emission tomography (PET), and single-photon emission computed tomography (SPECT). These tests are only performed if there is reason to suspect an underlying disease or as part of clinical studies.

A CT (computed tomography) scan is a much more sensitive imaging technique than x-ray, allowing high definition of not only the bony structures but also the soft tissues. Clear images of organs and structures, such as the brain, muscles, joints, veins and arteries, as well as of tumors and hemorrhages, may be obtained with or without the injection of contrasting dye.

Symptoms that Could Indicate a Serious Underlying Condition

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 by believing it to be one of their usual headaches. Such patients should call a doctor promptly if the quality of a headache or accompanying symptoms has changed. Everyone should call a doctor for any of the following symptoms:

• Sudden, severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke)
• Sudden, very severe headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm)
• Chronic or severe headaches that begin after age 50
• Headaches in the back of the head accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of small stroke in the base of the skull)
• Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage)
• Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of spinal meningitis)
• Headaches that increase with coughing or straining (possibility of brain swelling).
• A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma)
• A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and has no pulse; scalp is tender (possibility of temporal arteritis, which can cause blindness or even stroke if not treated)
• Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain)