Types of headache and their diagnosis

Headaches are among the most frequent health complaints throughout the population. Epidemiologic surveys show that around 70% of the population have a headache at least once a year, with women more often affected than men. Headache disorders are divided into primary and secondary (symptomatic) forms. The former are idiopathic disorders such as migraine and tension-type headache. The latter are warning symptoms of other diseases, such as sinusitis, tumour or cerebral bleeding. Although there are many different possible causes of symptomatic headaches, primary headache disorders are much more frequent, accounting for about 95% of all headaches.

To make the correct diagnosis, the physician needs a detailed account of the headache characteristics. He will ask you to describe the headache location (on one side or both sides of the head), headache intensity, type of pain (dull, stabbing, throbbing) and accompanying symptoms (e.g., nausea, increased sensitivity to light or sounds, fatigue, red eyes). The duration of attacks, triggering factors (e.g., stress, menstruation), attack frequency (daily, two times per month, etc.), headache history (new headache vs. long-standing headache) and present and previous treatment (during attacks, prophylactic) are also important.

Some patients suffer from more than one type of headache. When headaches are long-standing, keeping a headache diary for some weeks may be useful before an appointment at the doctor’s.

A physical examination is performed before making a diagnosis. In primary headaches, the physical examination is usually normal, or (abnormal) findings are not related to the headache. If headache symptoms are typical for a primary headache type (e.g. migraine) and physical examination is normal, no further examinations (e.g. electroencephalography, imaging of the brain) are necessary.

Additional investigations, as recommended by the doctor, are only necessary when a symptomatic headache is suspected. Not all symptomatic headaches can be diagnosed using computed tomography or magnetic resonance imaging of the brain. Sometimes blood tests, ultrasound examinations or a spinal tap are required. 

At what point should I consult a doctor?

Many types of headache are unproblematic and can be treated with over-the-counter drugs as long as they occur only occasionally. When headaches occur on a regular basis, or do not respond satisfactorily to analgesics or increase in frequency, a doctor should be consulted. Headache patients that regularly take painkillers on more than 8 to 10 days per month should also make a doctor’s appointment.

A symptomatic headache is suspected when a new headache occurs on a daily or almost daily basis from the beginning, when the character of pre-existing headaches changes, or when fever or neurological symptoms occur (e.g. muscle weakness or palsy, sensory disturbances, changes in personality). Extremely intense headaches that reach their maximum within seconds or minutes indicate an emergency that requires immediate medical attention. The same is true when headache occurs together with meningism, significant fever, epileptic seizures or other disturbances of consciousness or acute neurologic deficits.