Diagnosis of headache

According to MKGB-2, with the primary forms of headache, anamnesis, physical and neurological examinations, and additional methods of investigation do not reveal the organic cause of pain, i.e. Exclude the secondary nature of cephalalgia. For secondary headaches, there is a close temporal connection between the onset of cephalalgia and the onset of the disease, the increased clinical symptoms of headache in exacerbations of the disease, and the alleviation of cephalalgia with the reduction of symptoms or the cure of the disease. The cause of the headache can be established through the collection of anamnesis, physical and neurological examinations, as well as additional research methods.

Diagnosis of primary forms of headache is based solely on the basis of complaints and data of anamnesis.

Questions addressed to the patient with a headache

How many types of headaches do you experience? (It is necessary to ask in detail about each of them)

Time of occurrence and duration	Why did you go to the doctor right now? How long have you had headaches? How often do they arise? What happens pain: episodic or chronic (constant or almost constant)? How long does it last?
Character	Intensity. The nature (quality) of pain. Localization and distribution. Harbinger (prodrom). Concomitant symptoms. Condition after an attack of a headache (postdrome)
Causes	Predisposing factors (provokers of pain). Factors that aggravate and relieve the headache. The history of similar headaches in the family
Impact of a headache on a patient and measures taken	Behavior of the patient during an attack of a headache. The degree of disruption of daily activity and performance during an attack. What do you take from a headache and how effective is it?
Condition between seizures	Are any symptoms or feelings normal? Other concomitant (comorbid) disorders. Emotional condition

Physical examination

In the vast majority of patients with primary cephalalgia, no neurologic symptoms are seen on examination. Only an attack of bundle headache is accompanied by bright vegetative manifestations: lacrimation, rhinorrhea, sweating. Disturbing symptoms in the patient during an attack of a headache are hyperthermia and the presence of local neurological signs. However, in cases where the doctor has the slightest doubt about the benign nature of the attacks of cephalgia, as well as in the presence of symptoms, a thorough examination (CT, MRI, EEG, ultrasound, lumbar puncture, neuro-ophthalmologic examination, etc.) should be performed to rule out the organic cause of cephalgia .

Danger signals for headache

Signal	Possible reason
Sudden appearance of a strong "thunderous" headache	Subarachnoid haemorrhage
Headache with an atypical aura (lasting more than 1 h or with symptoms of weakness in the extremities)	Transient ischemic attack or stroke
Aura without cephalgia in a patient without a previous history of migraine	Transient ischemic attack or stroke
Aura, first appeared on the background of taking hormonal contraceptives	Risk of stroke
The first headache in a patient over 50 years old	Temporal arteritis
The first headache in a child	Intracranial swelling
Cefalgia, progressively increasing over several weeks, months	Progressive volumetric process
Increased headache when changing the position of the head or loads associated with increased intracranial pressure (physical stress, coughing, straining, sneezing)	Intracranial swelling

The first headache in a patient with an oncological process, HIV infection, or an immunodeficient condition in the anamnesis

Other danger signals: a change in the sphere of consciousness (deafness, confusion or memory loss), the presence of focal neurological signs or symptoms of a systemic disease (fever, arthralgia, myalgia)

Laboratory and instrumental methods of diagnosis of headache

In primary cephalalgia, most traditional methods of investigation (EEG, REG, radiography of the skull, methods of neuroimaging - CT and MRI) are of little informative, i.e. Do not reveal a pathology that explains the cause of the headache. With TCDD and duplex scanning of cerebral vessels, many patients experience nonspecific changes: signs of venous outflow disturbance, a decrease in the blood flow velocity in the basins of some arteries, a spondylogenic effect on the blood flow in the vertebral arteries. On the roentgenograms of the cervical spine, dystrophic and deformational changes are often found. Additional examinations, including neuroimaging and specialist consultations (neurologist, vertebro neurologist, neurosurgeon, psychiatrist) are indicated if there are suspicions of symptomatic headache.

It should be noted that the patient may have several types of headache at the same time, therefore, several diagnoses can be made to one patient (in the setting of several diagnoses, they should be placed in order of importance for the patient).

In the presence of several types of headaches, to clarify their nature, one can offer the patient a diary of cephalgia, which will help him learn to distinguish one type of headache from another. A doctor of such a diary will facilitate the diagnosis and an objective assessment of the amount of pain medication used by the patient. The primary forms of headache include the following:

• migraine;
• tension headache;
• cluster (cluster) headache and other trigeminal vegetative cephalalgia;
• other primary headaches.

In addition, in this section, special attention will be paid to one form of benign secondary headache - drug-induced, or abusus, headache, often accompanying migraine and tension headache. The frequency of abusus headache has increased significantly in recent years.

Examination with severe headache

Optimum treatment of a patient delivered to an emergency room with an intense headache is not possible for rapid diagnosis. At the same time, first of all it is necessary to decide whether in this case there is a serious episode of primary headache or pain is secondary and is associated with a potentially dangerous disease. Some elements of anamnesis and physical examination are key in this differential diagnosis.

Anamnestic data indicating a relationship between headache and a "serious" disease

1. If the patient has never experienced such a headache before, the likelihood of symptomatic headache increases. If such seizures were noted earlier for many months or years, then this indicates a benign condition. At the age of over 40 years the probability of the first migraine attack decreases, and the probability of a tumor or other intracranial pathology increases.
2. If the headache starts suddenly, reaches its maximum intensity within a few minutes and lasts for several hours, it is always a reason for a serious examination. The headache that arose during subarachnoid hemorrhage, the patients describe as a feeling, "as if they were hit with a baseball bat on the head". In primary forms of headache, such as migraine or tension headache, the pain reaches a maximum of at least half an hour or an hour. Although with a cluster headache, sensations rapidly increase, they usually last no longer than 3 hours.
3. If the consciousness or mental status changes in the previous period or simultaneously with a headache, an additional examination is necessary. Although migraine sufferers may appear tired, especially after prolonged vomiting or in connection with the use of a large dose of analgesics, confusion or confusion in primary headache are very rare. These symptoms are more likely to indicate intracranial hemorrhage or infection of the central nervous system, although they are possible with such poorly delineated and difficultly diagnosed syndromes as basilar migraine.
4. With a recent or concomitant infection of extracranial localization (for example, in the lungs, paranasal sinuses, mastoid process), the risk of secondary headache increases. These infectious foci can serve as a source for the subsequent development of CNS infection, for example, meningitis or brain abscess.
5. If the headache occurs against a background of intense physical exertion or physical effort, or soon after a head and neck injury, subarachnoid hemorrhage or carotid stratification should be assumed. Headache caused by physical effort, and coital migraine are relatively rare. Rapid development of the headache amid intense physical exertion, especially with slight head and neck injuries, should raise suspicions of carotid stratification or intracranial hemorrhage.
6. The spread of pain below the neck border in the back area is atypical for migraine and may indicate irritation of the meninges due to infection or hemorrhage.

Other anamnestic data that can help with the diagnosis of severe headache

1. Family history. Migraine often has a family character, whereas a secondary headache is usually sporadic.
2. Medications taken. Some drugs can cause headaches, and anticoagulants and antibiotics administered internally indicate the possibility of a hemorrhage or an untreated CNS infection.
3. Anamnesis of neurological disorders. The previously existing residual neurologic symptoms may make interpretation of the examination data difficult.
4. Localization of headache. Benign headache tends to change sides and localization, at least - sometimes.

Diagnostic inspection data

1. Rigidity of the neck muscles indicates meningitis or subarachnoid hemorrhage.
2. The optic discs of optic nerves are a sign of increased intracranial pressure, indicating the possibility of a tumor or hemorrhage and, therefore, signaling the need for additional examination.
3. Violation of consciousness or orientation of any kind requires an emergency additional examination.
4. External signs of intoxication. Fever is not characteristic of a primary headache. Even a slight increase in body temperature, as well as persistent tachycardia or bradycardia should be regarded as signs of a possible infectious disease.
5. Any previously not observed neurologic symptom.

New symptoms, for example, mild asymmetry of the pupils, lowering of the hand with its internal rotation in the Barre sample, a pathological stop sign increase the likelihood of finding a serious intracranial disease. It is important to examine the patient in dynamics with short intervals, as the neurological status may change.

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