EVALUATION OF HEADACHE: (1) Focused Exam: Vital signs can reveal hypotension, hypertension, or fever. General exam can reveal infectious signs such as sinus tenderness, erythematous tympanic membranes or throat, lymphadenopathy, and nuchal rigidity. Neurologic exam should focus on papilledema, visual acuity, eye movements, visual field testing, and weakness.
(2) Need for Imaging: Consider for patients with
red flags: waking up from sleep, change in headache quality or intensity, or associated neurologic symptoms or exam findings.
(3) Appropriate Brain Imaging: MRI: preferred due to absence of radiation, level of detail, and evaluation of posterior fossa. CT: consider for acute increase of
ICP (e.g., hemorrhage, mass lesion, or hydrocephalus), focal neurologic exam, unstable patient, or lack of
MRI availability.
(4) Vessel Imaging: CTA or MRA should be obtained for the evaluation of arterial dissection, cerebral hemorrhage, or cerebral infarction. If there is concern about a sinus venous, then CTV or MRV should be included. See Neuroimaging chapter for details.
(5) Laboratory: CBC,
ESR, serum or urine toxicology screens, thyroid function tests, and pregnancy screen.
(6) Headache Diary: Extremely helpful in establishing a diagnosis and monitoring improvement. Advise patient to mark intensity on a pain scale, quality, location, timing of menses, triggers, and associated symptoms such as an aura, neurologic symptoms, photophobia, phonophobia, nausea, or vomiting. Teenagers should be encouraged to keep their own diaries. Many sample headache calendars are available on the Internet. Examples include
www.childrenshospital .org/az/Site986/Documents/CHBMy_Headache_Diary.pdf (quite detailed), and the American Headache Society’s Committee for Headache Education has daily, weekly, and monthly versions of diaries on their website
www.achenet .org/resources/headache_diaries. Many smart phone applications are available to create digital calendars, tables, and graphs, all of which can be electronically included in the medical record.
(7) Other Evaluations: If there are signs of meningitis with acute presentation of headache with fever, neck pain, or nuchal rigidity; emergent
LP should be done. In idiopathic intracranial hypertension (
IIH), therapeutic
LP may also need to be done urgently if there are concerns about vision loss; otherwise, it can be done as an outpatient.
EEG is not usually recommended unless symptoms overlap with possibly ictal phenomenon such as paresthesias or weakness in one limb, stereotyped simple visual phenomenon, dysarthria, confusion, or decreased responsiveness. Headache can be an aura, ictal or postictal symptom.