Headache or Something More Serious? What Doctors Look for First
Introduction
Headache is a very common condition affecting a large part of the population. The main task of a family physician when evaluating a patient with headache is to determine whether the pain is benign or whether it may be caused by a neurological or systemic condition that could pose a threat to health or life.
The most common type of headache in clinical practice is tension-type headache, which affects up to 40% of the global population. Migraine affects approximately 10% of people, while cluster headache occurs in about 1% of the population (1, 2). In most cases, the diagnosis is based on a careful evaluation of the patient’s medical history (3).
The International Headache Society published a classification system and diagnostic criteria for headaches in 2004 (4). This classification is widely used in both epidemiological and clinical studies.
In everyday clinical practice, headaches are typically divided into two main groups: primary headaches (such as tension-type headache, migraine, and cluster headache) and secondary headaches, which are caused by underlying conditions such as infections, vascular disorders, or other diseases.
This classification helps physicians distinguish between patients whose headaches, although unpleasant and affecting quality of life, are not dangerous, and those whose headaches may be a symptom of a serious neurological or systemic disease requiring further investigation and specific treatment strategies.
Primary Headache
If a patient complaining of headache does not show symptoms or warning signs typical of secondary headaches, the likelihood of a serious underlying condition is low. However, the headache should still meet the characteristic features of primary headaches (Tables 1–5) (4, 5).
Criteria for identifying low-risk headaches are presented in Table 6 (6). When there is a low probability that the headache is caused by a serious condition, additional imaging studies are usually not necessary (7).
Table 1. International Headache Classification
| Primary Headache |
| Migraine |
| Tension-type headache |
| Cluster headache |
| Others (e.g., cold-induced headache) |
| Secondary Headache |
| • Headache related to head or neck trauma, head or neck vascular pathology, nonvascular intracranial pathology, medication or substance use or withdrawal, infections, homeostatic disturbances, mental disorders |
| • Head or facial pain caused by head, neck, eye, ear, nose, sinus, dental, oral, or other facial and (or) skull structure pathology |
Tension-Type Headache
Tension-type headache is the most common form of headache in clinical practice, affecting more than 40% of the global population (1). It is typically described as a mild to moderate, bilateral, pressing or tightening pain that is not accompanied by additional symptoms (4). This type of headache occurs slightly more often in women than in men (8).
It is believed that tension-type headache originates from pain receptors located in the pericranial myofascial tissues (9, 10). Research has shown that individuals with chronic tension-type headaches have increased sensitivity of these tissues to pressure, electrical, or thermal stimuli. In addition, such patients may experience pain even in response to normal, non-harmful stimuli (10–12).
If a patient presenting with symptoms typical of tension-type headache shows no abnormalities during a neurological examination, further laboratory or instrumental investigations are usually not required (13). The diagnostic criteria for tension-type headache are provided in Table 2 (5).
Table 2. Diagnostic criteria for infrequent episodic tension-type headaches
| Infrequent episodic tension-type headache |
| Headache occurring less than 12 times a year and less than once a month (total of at least 10 episodes), characterized by: • Headache lasting from 30 minutes to 7 days • Presenting with at least 2 of these features: bilateral, pressing or tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity such as climbing stairs or walking on level ground • Absence of nausea or vomiting, but presence of photophobia or phonophobia • Pain not caused by another disorder or condition |
| Frequent episodic headache |
| Headache occurring for more than 3 months, more than 1 day but less than 15 days per month (at least 10 episodes), with the same characteristics as infrequent episodic tension-type headaches (see above) |
Migraine
Distinguishing migraine from tension-type headache is often based on the presence of typical migraine symptoms, such as nausea, photophobia (increased sensitivity to light), and phonophobia (increased sensitivity to sound). Physical activity usually worsens the intensity of migraine pain.
A comprehensive evaluation of symptoms is essential for accurate diagnosis. If at least four of the following features are present—pulsating pain, duration of 4 to 72 hours, unilateral localization, nausea or vomiting, and high pain intensity—the diagnosis of migraine is highly likely (14, 15).
Some patients with migraine experience an aura. An aura consists of visual, sensory, or speech disturbances that develop gradually, last no longer than 60 minutes, and resolve spontaneously.
The diagnostic criteria for migraine with aura (Table 3) and migraine without aura (Table 4) are presented separately.
Table 3. Diagnostic criteria for migraines with aura
| At least two episodes meeting the following criteria: |
| • Aura consisting of at least one of the following symptoms, without motor weakness: fully reversible visual disturbances (such as flashes, spots, lines, shimmering lights, blind spots, or temporary vision loss), sensory disturbances (such as tingling, “pins and needles,” numbness, or reduced sensation), or speech disturbances. |
| • At least two of the following characteristics: homonymous visual symptoms and/or unilateral symptoms; at least one aura symptom that develops gradually over 5 or more minutes, or multiple symptoms occurring in succession over 5 or more minutes; each symptom lasts at least 5 minutes but no longer than 60 minutes. |
| • A migraine-type headache (see Table 4) that begins during the aura or follows the aura within 60 minutes after its onset. |
Table 4. Diagnostic criteria for migraines without aura
Cluster HeadacheCluster headache is diagnosed relatively rarely, but it is one of the most severe forms of headache. It is characterized by sudden-onset attacks of very intense pain lasting 15 to 180 minutes and accompanied by symptoms of autonomic nervous system dysfunction (Table 5) (1, 4). Although cluster headaches are much less common than tension-type headaches or migraines, it is estimated that about half a million people in the United States experience this condition at least once in their lifetime (16). Cluster headaches can occur at various ages, but approximately 70% of cases develop before the age of 30 (17). Patients typically describe the pain as sharp, though it may also be pulsating or pressing. While cluster headaches can occur on both sides, they are most often unilateral. The pain is usually located around or behind one eye, but it may also occur in the temple, upper or lower jaw, teeth, forehead, or neck. Typically, the pain appears on one side of the head, accompanied by autonomic symptoms on the same side, such as eyelid swelling, nasal congestion, tearing, or sweating of the forehead. Attacks may occur several times a day (up to eight episodes) and last between 15 and 180 minutes (4). The most common form is episodic cluster headache, affecting about 80–90% of patients. In this form, attacks occur daily for several weeks, followed by a remission period when symptoms disappear (4). These episodes usually recur in cycles lasting 3 to 12 weeks, with remission periods often lasting around 12 months. In the chronic form, which affects about 10–20% of patients, attacks occur continuously without significant remission periods (4). Cluster headache is frequently diagnosed late. Only about 25% of patients receive a correct diagnosis within the first year of symptom onset (16), and up to 40% remain undiagnosed even after five years (16). The condition is most often misdiagnosed as migraine (34%), followed by sinusitis (21%) and allergic diseases (6%) (15). Family history may also play a role. Patients with cluster headache often have other chronic conditions, including depression (24%), sleep apnea (14%), restless legs syndrome (11%), and asthma (9%) (15). In recent years, increasing attention has been paid to the importance of managing depression in these patients, as many report experiencing suicidal thoughts. Approximately 2% of individuals with cluster headache have attempted suicide at least once (16, 18, 19). Table 5. Diagnostic criteria for cluster headache
Threatening HeadacheDistinguishing a potentially life-threatening headache from a benign (low-risk) one is not always straightforward, making differential diagnosis a significant challenge in clinical practice. Certain clinical warning signs—often summarized in Table 7—can help identify headaches that may be caused by serious underlying conditions (5, 20–24). These warning signs have been identified through retrospective clinical studies and expert consensus, but they are not always precise in determining the exact cause. When a patient presents with symptoms suggestive of a secondary headache, the physician must carefully evaluate the level of risk and decide on appropriate further investigations. In cases of acute head trauma, computed tomography (CT) of the brain is typically the first diagnostic choice, as it is widely available, fast, and reliable. However, magnetic resonance imaging (MRI) is more sensitive in detecting subdural bleeding and small intracranial lesions (20). Table 6. Criteria for Low-Risk Headache
Table 7. Evaluation of a Patient with Acute Headache: Signs and Symptoms of Potentially Life-Threatening Conditions
Medical History and Patient ExaminationA headache that begins suddenly and reaches maximum intensity within a few minutes should always be considered a serious warning sign. Rapid patient assessment is essential in such cases. This type of pain is characteristic of conditions such as subarachnoid hemorrhage, hypertensive crisis, vertebral artery dissection, acute angle-closure glaucoma, and others. The use of psychoactive substances, such as cocaine or methamphetamine, increases the risk of intracranial hemorrhage and stroke. The risk of intracranial bleeding is also elevated with certain over-the-counter and prescription medications, including aspirin, nonsteroidal anti-inflammatory drugs, anticoagulants, and glucocorticoids. If a patient with human immunodeficiency virus (HIV) infection or another form of immunodeficiency presents with headache, potential causes include brain abscess, meningitis, or central nervous system (CNS) tumors. Infections affecting the CNS may spread from nearby structures such as the lungs, paranasal sinuses, or eyes. Patients who describe their headache as the “worst ever” require particularly careful evaluation, especially if they are older than 50 years or if the pain intensifies during physical activity (including sexual activity). These features may indicate intracranial hemorrhage or vertebral artery dissection. Patients with headaches accompanied by neurological symptoms—such as altered consciousness, seizures, or visual disturbances—must be assessed urgently. Warning signs suggestive of serious underlying causes are summarized in Table 7 (5, 20–24). The likelihood of CNS pathology increases significantly when objective neurological deficits are present (6, 14, 27). Although migraine can be associated with focal neurological symptoms, the first occurrence of such symptoms in a patient should always raise suspicion of a serious condition. According to the definition of migraine with aura, aura symptoms should not last longer than 60 minutes. Therefore, any aura-like symptoms persisting beyond this duration require urgent medical evaluation. Clinical examination may reveal both obvious and subtle signs. Severe findings include meningeal signs or loss of vision in one eye, while more subtle abnormalities may include reduced peripheral reflexes. Altered consciousness and psychomotor agitation are typical of serious CNS disorders. If headache is accompanied by fever, optic disc edema (papilledema), or severe hypertension (systolic blood pressure greater than 180 mm Hg or diastolic blood pressure greater than 120 mm Hg), CNS infection and other causes of increased intracranial pressure must be excluded. In patients with hypertension, it is also important to assess whether blood pressure can be safely reduced to prevent hemorrhagic complications. A history of trauma or visible bruising increases the likelihood of intracranial bleeding (Table 7) (5, 20–24). Instrumental and Laboratory DiagnosticsImaging StudiesNeuroimaging should be performed in all patients presenting with signs and symptoms of severe or potentially dangerous headache, as these individuals have a higher risk of underlying structural brain disease. Although there is still ongoing debate regarding the optimal evaluation of patients presenting with acute severe headache, the American College of Radiology has published practical recommendations for imaging in such cases (Table 8) (28). Table 8. Evaluation of a Patient with Headache Using Imaging Methods (American College of Radiology Recommendations)
CT – computed tomography, CTA – computed tomography angiography, MRI – magnetic resonance imaging, MRA – magnetic resonance angiography Lumbar PunctureLumbar puncture and cerebrospinal fluid (CSF) analysis can provide important diagnostic information, particularly in cases of suspected central nervous system (CNS) infections. The presence of red blood cells in the CSF may indicate intracranial bleeding, while morphologically abnormal cells may suggest an oncological process. In adults with suspected subarachnoid hemorrhage, lumbar puncture is an essential diagnostic procedure, as it allows detection of blood in the CSF. Prior to performing a lumbar puncture, a brain CT scan should be carried out to exclude conditions such as increased intracranial pressure. This recommendation applies even when no abnormalities are found during the neurological examination (29). Publication: “Internistas”, No. 1, 2018 |
