A Systematic Approach to Adult Headache: Clinical Suspicion, Diagnosis, and Evidence-Based Workup

Dr Neeraj Manikath, Claude.ai

Abstract

Background: Headache represents one of the most common presenting complaints in clinical practice, affecting up to 96% of adults at some point in their lives. While most headaches are benign primary disorders, distinguishing between primary and secondary headaches remains a critical clinical challenge.

Objective: To provide a systematic, evidence-based approach to adult headache evaluation, incorporating recent advances in diagnostic criteria and imaging recommendations.

Methods: Comprehensive review of current literature, international headache society guidelines, and evidence-based diagnostic approaches.

Results: A structured framework for headache evaluation emphasizing pattern recognition, red flag identification, and judicious use of diagnostic testing.

Conclusion: Systematic application of established diagnostic criteria, combined with careful attention to warning signs, enables accurate diagnosis while avoiding unnecessary investigations in most patients.

Keywords: Headache, migraine, tension-type headache, secondary headache, diagnostic workup

Introduction

Headache disorders affect approximately 3 billion people worldwide, representing a significant burden on healthcare systems and individual quality of life.¹ The International Classification of Headache Disorders, 3rd edition (ICHD-3) provides the current diagnostic framework, categorizing headaches into primary disorders (migraine, tension-type, cluster) and secondary headaches due to underlying pathology.²

The clinical challenge lies not in diagnosing headache per se, but in distinguishing benign primary headaches from potentially life-threatening secondary causes while avoiding excessive diagnostic testing in low-risk patients.

Step 1: Clinical Suspicion - The Art of Pattern Recognition

Initial Assessment Framework

The foundation of headache diagnosis rests on systematic history-taking using the mnemonic SOCRATES-PLUS:

Site: Unilateral vs bilateral, specific anatomical location
Onset: Sudden vs gradual, temporal pattern
Character: Quality of pain (throbbing, pressing, stabbing)
Radiation: Associated symptoms, aura phenomena
Associations: Nausea, photophobia, phonophobia
Timing: Duration, frequency, circadian patterns
Exacerbating/alleviating factors
Severity: Functional impact, disability
Precipitants: Triggers, hormonal factors
Lifestyle impact: Work, social, family effects
Urgent features: Red flags (detailed below)
Similar episodes: Previous headache history

🔍 Clinical Pearl: The "Headache Calendar"

Encourage patients to maintain a headache diary for 4-6 weeks. This reveals patterns invisible in single consultations and dramatically improves diagnostic accuracy.

Step 2: Red Flag Recognition - When to Worry

Primary Red Flags (SNOOP4)

S - Systemic symptoms or illness N - Neurologic symptoms or signs O - Onset sudden or split-second O - Onset in older patients (>50 years) P - Pattern change or recent onset P - Positional component P - Precipitated by exertion or Valsalva P- Papilledema or visual disturbances

Secondary Red Flags

Temporal characteristics: "Thunderclap" onset, "worst headache of life"
Associated symptoms: Fever, neck stiffness, altered consciousness
Population-specific: Pregnancy, immunocompromised state, cancer history
Examination findings: Focal neurological deficits, cognitive changes

🚨 Clinical Hack: The "5-Minute Rule"

If a previously headache-free patient describes onset within 5 minutes, consider subarachnoid hemorrhage until proven otherwise. Normal CT within 6 hours has 98% sensitivity, but LP may still be required.³

Step 3: Systematic Diagnostic Approach

Primary Headache Diagnosis

Migraine (ICHD-3 Criteria)

A. At least 5 attacks fulfilling criteria B-D B. Duration 4-72 hours (untreated) C. At least 2 of:

Unilateral location
Pulsating quality
Moderate to severe intensity
Aggravated by routine physical activity

D. At least 1 of:

Nausea and/or vomiting
Photophobia and phonophobia

Tension-Type Headache

A. At least 10 episodes fulfilling criteria B-D B. Duration 30 minutes to 7 days C. At least 2 of:

Bilateral location
Pressing/tightening quality
Mild to moderate intensity
Not aggravated by routine physical activity

D. Both of:

No nausea or vomiting
No more than one of photophobia or phonophobia

Cluster Headache

A. At least 5 attacks fulfilling criteria B-D B. Severe unilateral orbital/temporal pain C. Duration 15-180 minutes if untreated D. At least 1 ipsilateral autonomic feature

💎 Diagnostic Oyster: Migraine Mimics

Beware of "pseudomigraine with pleocytosis" - transient neurologic symptoms with CSF pleocytosis but normal imaging. Self-limiting but can mimic serious pathology.

Step 4: Evidence-Based Workup Strategy

Neuroimaging Decision Framework

Indications for URGENT imaging (CT ± CTA/MRI)

Thunderclap headache
Headache with focal neurological deficits
Headache with papilledema
Headache with altered mental status
New headache in patients >50 years with temporal artery tenderness

Indications for NON-URGENT imaging (MRI preferred)

Significant change in headache pattern
Headache with atypical features
Progressive headache over weeks/months
Headache associated with seizures
Headache in immunocompromised patients

Evidence-Based Imaging Guidelines:

CT sensitivity for SAH: 98% within 6 hours, 93% at 24 hours⁴
MRI superiority: Better for posterior fossa, vascular malformations, and white matter lesions
Venography indications: Suspected cerebral venous thrombosis (headache + papilledema)

Laboratory Investigations

Routine blood work is NOT indicated for typical primary headaches

Consider laboratory studies when:

Fever present: CBC, blood cultures, inflammatory markers
Suspected giant cell arteritis: ESR, CRP (ESR >50 mm/hr in >90% of cases)
Suspected secondary causes: Thyroid function, B12, folate
Medication overuse suspected: Comprehensive metabolic panel

🎯 Clinical Hack: The "Normal Neurological Exam Rule"

In patients under 50 with typical primary headache features and completely normal neurological examination, neuroimaging yield is <1% for clinically significant abnormalities.⁵

Step 5: Special Considerations and Clinical Pearls

Age-Specific Considerations

New Headache After Age 50:

Giant cell arteritis (temporal tenderness, jaw claudication, visual symptoms)
Mass lesions (progressive pattern, cognitive changes)
Medication-related (polypharmacy interactions)

Reproductive Age Women:

Menstrual migraine patterns
Pregnancy-related headaches (preeclampsia, cerebral venous thrombosis)
Hormonal contraceptive effects

Medication Overuse Headache (MOH)

Critical diagnostic criteria:

Headache >15 days/month in patient with primary headache disorder
Regular overuse of acute headache medication >3 months
Simple analgesics: >15 days/month
Triptans/ergots: >10 days/month

🔑 Clinical Pearl: The "Bounce-Back Test"

Patients with MOH typically experience worsening headaches 2-3 days after stopping overused medications. This "rebound" pattern is diagnostic.

Step 6: Diagnostic Dos and Don'ts

✅ DO:

Use validated diagnostic criteria consistently
Document headache characteristics systematically
Screen for red flags at every encounter
Consider medication overuse in chronic daily headache
Educate patients about their diagnosis and triggers
Reassure patients with benign diagnoses appropriately

❌ DON'T:

Order routine imaging for typical primary headaches
Ignore pattern changes in established headache patients
Dismiss headaches in elderly patients as "normal aging"
Forget to ask about medication overuse
Overlook psychiatric comorbidities (depression, anxiety)
Use outdated terminology ("vascular headache," "sinus headache")

🚫 Common Pitfalls to Avoid:

"Sinus headache" overdiagnosis - Most are actually migraine with nasal symptoms
Cervicogenic headache overattribution - Neck pain is common in migraine
Imaging all "severe" headaches - Severity doesn't correlate with secondary causes
Missing giant cell arteritis - Consider in all new headaches >50 years

Step 7: Advanced Diagnostic Considerations

When Standard Workup is Negative

Consider specialized testing for:

CSF analysis: Suspected infection, inflammatory conditions, intracranial hypotension
Temporal artery biopsy: Suspected GCA with high clinical suspicion
24-hour blood pressure monitoring: Suspected hypertensive headaches
Sleep study: Cluster headache with sleep-disordered breathing

Emerging Diagnostic Tools

CGRP levels: Research tool, not yet clinically validated
Advanced MRI techniques: Arterial spin labeling for migraine research
Genetic testing: Limited to specific familial syndromes (CADASIL, familial hemiplegic migraine)

Treatment Implications of Accurate Diagnosis

Precision Medicine Approach

Accurate phenotyping enables:

Targeted acute therapies (triptans for migraine, oxygen for cluster)
Appropriate preventive strategies
Lifestyle modification counseling
Comorbidity management
Prognosis discussion

💡 Teaching Pearl: The "Therapeutic Trial" Concept

Response to migraine-specific therapy (triptan response) can support diagnostic uncertainty in borderline cases, but should not replace systematic clinical assessment.

Quality Improvement and Systematic Approach

Implementing Systematic Care

Standardized Assessment Tools:

Validated questionnaires (HIT-6, MIDAS)
Electronic health record templates
Clinical decision support systems
Provider education programs

Quality Metrics:

Diagnostic accuracy rates
Appropriate imaging utilization
Patient satisfaction scores
Time to accurate diagnosis

Conclusion

Systematic evaluation of adult headache requires integration of pattern recognition, evidence-based diagnostic criteria, and judicious use of investigations. The vast majority of headaches represent benign primary disorders that can be accurately diagnosed through careful clinical assessment without extensive testing.

The key to successful headache management lies in developing systematic approaches that reliably identify the small percentage of patients with secondary headaches requiring urgent intervention while providing appropriate reassurance and treatment for those with primary headache disorders.

Future directions include development of biomarkers for headache subtypes, improved imaging techniques, and personalized medicine approaches based on genetic and phenotypic profiling.

References

Stovner LJ, Nichols E, Steiner TJ, et al. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976.
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310(12):1248-1255.
Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke. 2016;47(3):750-755.
Choosing Wisely Campaign. American Headache Society. Five Things Physicians and Patients Should Question. Available at: https://www.choosingwisely.org/societies/american-headache-society/
Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144.
Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
Singh RB, Sung S, Khurana D. Neuroimaging in headache. Neurol India. 2019;67(7):1645-1654.
Rozen TD. Emergency department and urgent care of headache. Headache. 2018;58(8):1081-1091.
American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2019;74(4):e41-e74.

Corresponding Author:Dr Neeraj Manikath. Conflicts of Interest: None declared Funding: None Word Count:[Approximately 2,200 words]

Thursday, June 5, 2025

Approach to Headache