How are headaches evaluated and diagnosed?
The correct headache diagnosis is needed to begin an effective treatment plan. The most important aspect of the headache evaluation is the headache history, which is obtained from the patient. It is important for you to describe your headache symptoms and characteristics to your doctor as completely as possible so the headache can be properly diagnosed and successfully treated. Your headache can be more accurately diagnosed by knowing:
- When the headache started
- How long you have had the headache
- Whether there is a single type of headache or multiple types of headaches
- How often the headache occurs
- What causes the headache, if known (for example, do certain situations, foods, or medications usually trigger the headache?)
- If physical activity aggravates the headache pain
- What events are associated with the headache
- Who else in your family has headaches
- What symptoms, if any, occur between headaches
Your doctor will also ask additional questions about performance at work, family background, and if there is any history of drug abuse.
Clinical description of headaches
Describe how you feel when you have the headache and what happens when you get the headache, such as:
- Where the pain is located
- What it feels like
- How severe the headache pain is, using a scale from one (mild) to 10 (severe)
- If the headache appears suddenly without warning or with accompanying symptoms
- What time of day the headache usually occurs
- If there is an aura (changes in vision, blind spots, or bright lights) before the headache
- What other symptoms or warning signs occur with the headache (weakness, nausea, sensitivity to light or noise, decreased appetite, changes in attitude or behavior)
- How long the headache lasts
History of headache treatments
You should provide your physician with a history of prior headache treatments. Tell your doctor what medications you have taken in the past and what medications are you currently taking. Don't hesitate to list them, bring in the medication bottles, or ask your pharmacist for a printout.
If any studies or tests were previously performed, bring them with you. This may save time and repetition of tests.
Physical and neurological examinations
After completing the medical history part of the evaluation, your physician will perform physical and neurological examinations. The physician will look for signs and symptoms of an illness that may be causing the headache. These signs and symptoms can include: fever, infection, high blood pressure, muscle weakness, balance problems, or vision problems.
After evaluating the results of your headache history, physical examination, and neurological examination, your physician should be able to determine what type of headache you have, whether or not a serious problem is present, and whether additional tests are needed.
When additional tests may be needed
If the results of the physical exam show signs of a condition within your brain that may be causing the headaches (organic cause), additional laboratory tests may be needed.
An imaging test called a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan may be recommended if a structural disorder of the central nervous system is suspected. Both of these tests produce cross-sectional images of the brain that can reveal problems within the brain.
Skull X-rays are not helpful. An electroencephalogram (EEG) is also unnecessary unless a person has lost consciousness with his or her headaches.
How are headaches treated?
The proper treatment will depend on several factors, including the type and frequency of the headache and its cause. Treatment may include education, stress management, biofeedback, and medication and physical therapy education.
Education includes learning and recording what triggers the headaches, such as lack of sleep, a poor diet, your environment, or stress. Your health care provider may give you a Headache Diary to record the characteristics of your headaches and can recommend ways of managing headache triggers. Bring the diary with you to all of your doctor appointments; this information will help your healthcare providers correctly treat your headaches.
Learning relaxation techniques can help you reduce headaches. If you have a headache, you should:
- Lie down and relax
- Stretch and relax the muscles
- Take breaks from activities that trigger or provoke headaches, such as using the computer for long periods of time or exercising strenuously
There are several other methods you can use to relax or reduce stress, including:
- Deep breathing exercises
- Progressive muscle relaxation
- Mental imagery relaxation
- Relaxation to music
- Biofeedback (explained below)
- Counseling, which can help you recognize and release stress
Biofeedback can help you learn stress-reduction skills by providing information about muscle tension, heart rate, and other vital signs as you try to relax. It is used to gain control over certain bodily functions which cause tension and physical pain.
Biofeedback can be used to help you learn how your body responds in stressful situations. If a headache, such as a migraine, begins slowly, many people can use biofeedback to stop the attack before it becomes full blown.
Medications may be recommended to manage headache pain. Headache medications can be grouped into three different categories: symptomatic relief, abortive therapy, and preventive therapy. Each type of medication is most effective when used in combination with other medical recommendations, such as dietary and lifestyle changes, exercise, and relaxation therapy.
- Symptomatic relief - Used to relieve symptoms associated with headaches, including the pain of a headache or the nausea and vomiting associated with migraine. These may include simple analgesics, ibuprofen or acetaminophen, antiemetics or sedatives. Many of these are available over-the-counter, while others require a prescription.
Important: If symptomatic relief medications are used more than twice a week, you should see your healthcare provider who can prescribe preventive headache medications. Overuse of these symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.
- Abortive therapy - These medications are most effective when used at the first sign of a migraine to stop the process that causes the headache pain. By stopping the headache process, abortive medications help prevent the symptoms of migraines including pain, nausea, light sensitivity, etc. Abortive medications include: injectable dihydroergotamine mesylate (DHE-45®, and nasal Migranal, sumatriptan succinate (Imitrex®), zolmitriptan (Zomig®), and others triptan drugs.
- Preventive therapy - Used to treat very frequent tension headaches and migraines, or the combination of both types of headaches. Preventive therapy is aimed at reducing both the frequency and severity of the headaches and includes antidepressants, antihistamines, beta blockers, calcium channel blockers, and anticonvulsant medications as recommended by your doctor. Most of these medications require a prescription.
There are a variety of supplements that can be used daily to prevent migraines. These include riboflavin, coenzyme Q10, petadolex (butterbur) and magnesium oxide. These may be taken individually or in combination, but must be taken for more than 2 months to be effective.
What happens next?
When your physician starts a treatment program, keep track of the results and how the treatment program is working. Keep your scheduled follow-up appointments with your healthcare provider so that he or she can monitor your progress and make changes in your treatment program if necessary.
For the refractory migraine sufferer, there are programs available that utilize combinations of physical therapy, psychological therapy and medical therapy over a period of several weeks. The goal of such programs is to improve functioning and quality of life even if the migraines cannot be eradicated. Your physician can refer you to one of these for evaluation.
Do adults "outgrow" headaches?
Headaches may improve over time. The headaches may disappear and then return later in life. Migraines can go away as soon as a year after they first appear, even without treatment, or they may remain for life.