Diagnosis
In two surveys, patients reported a delay in the diagnosis of their headaches of between one and six years. In one of the surveys, the presence of migraine-like symptoms (light and sound sensitivity and nausea) were major reasons for the frequent misdiagnosis by family physicians. About a third of the patients sought help from dentists and another third from ear-nose-throat specialists. In most of cases, patients were inappropriately treated for other headaches (including having sinus surgery).
Medical and Personal History
For an accurate diagnosis, the patient should describe the following:
- Duration and frequency of headaches.
- Recent changes in their character.
- The location of the pain.
- The type (e.g., throbbing or steady pressure).
- The intensity of the headache.
- Associated symptoms, such as visual disturbances or nausea and vomiting. (These are seen most often with migraines.)
- Behaviors during a headache.
- Snoring, sleep disturbances, and daytime sleepiness (which could relate to sleep apnea, a possible risk factor for cluster headaches.)
Headache Diary to Identify Triggers
The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches. Some tips include the following:
- Be sure to include all events preceding an attack. Often two or more triggers interact to produce a headache. Experts are investigating triggers of headaches to determine if certain ones are more likely to set off different primary headaches.
- Tracking medications is an important way of identifying so-called rebound headaches, which can arise when drugs that are taken frequently are discontinued.
- Be sure to attempt to define the intensity of the headache. It may be indicated by using a number system:
1 = mild, barely noticeable.
2 = noticeable, but does not interfere with work/activities.
3 = distracts from work/activities.
4 = makes work/activities very difficult.
5 = incapacitating.
Physical Examination
In order to diagnose a chronic headache, the physician will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The physician will also examine the eyes to rule out pressure build-up in the eye as a cause of headache. The physician may ask questions to test short-term memory and related aspects of mental function.
Ruling Out Other Headaches and Medical Disorders
As part of the diagnosis the physician should rule out other headaches and disorders. If the results of the history and physical examination suggest other or accompanying causes of headaches or serious complications, extensive imaging tests are performed.
Migraines. Cluster headaches are often misdiagnosed as migraines but they are quite different:
- Frequency and Duration: Cluster headache attacks generally lasts 15 minutes to a few hours and can occur several times a day. A single migraine attack is continuous over the course of one or several days.
- Behavior. Cluster headache sufferers tend to move about while migraine sufferers usually want to lie down.
Nevertheless, in both cases, the headache suffers can be highly sensitive to light and noise, which may make it difficult to distinguish between them.
Other Headaches. Other headaches that resemble migraines include SUNCT and chronic paroxysmal hemicrania, which are other primary headaches, and some secondary headaches notably trigeminal neuralgia (TN), temporal arteritis, and sinus headaches. Cluster symptoms, however, are usually precise enough to rule out these other types of headaches.
Tear in the Carotid Artery. Of note, in one case a tear in the carotid artery (which leads to the brain) caused a headache that very closely resembled a cluster headache and even responded to sumatriptan, a drug used to treat a cluster attack. Physicians should consider imaging tests for patients with a first episode of cluster headache in which this event is suspected.
Orbital Myositis. An unusual condition called orbital myositis, which produces swelling of the muscles around the eye, may mimic symptoms of cluster headache. This condition should be considered in patients who have unusual symptoms such as protrusion of the eyeball, painful eye movements, or pain that does not dissipate within three hours.
Imaging Tests
Imaging tests of the brain may be recommended under the following circumstances:
- If the results of the history and physical examination suggest neurologic problems.
- If headaches wake patients during the night.
- If new headaches develop in the elderly. In this age group, it is particularly important to first rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls).
- If headaches are becoming worse.
Imaging tests are not recommended for patients with migraines and no other abnormal indications.
The following tests may be used:
- A CT (computed tomography) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis.
- X-rays and other tests may also be used if sinusitis is strongly suspected.
- A neck x-ray can reveal arthritis or spinal problems.
- Other tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, which are only performed if there is reason to suspect an underlying disease.
Headache Symptoms That Could Indicate Serious Underlying Disorders
Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. (It should again be emphasized that a headache is not a common symptom of a brain tumor.) People with existing chronic headaches, however, might miss a more serious condition believing it to be one of their usual headaches. Such patients should call a physician promptly if the quality of a headache or accompanying symptoms has changed. Everyone should call a physician for any of the following symptoms:
- Sudden, severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke).
- Sudden, very severe headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm).
- Chronic or severe headaches that begin after age 50.
- Headaches in the back of the head accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of small stroke in the base of the skull).
- Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage).
- Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of spinal meningitis).
- Headaches that increase with coughing or straining (possibility of brain swelling).
- A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma).
- A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and has no pulse; scalp is tender (possibility of temporal arteritis, which can cause blindness or even stroke if not treated).
- Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain).
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