Evaluation and Diagnosis
61
Complete detailed testing
to determine possible
secondary causes
YES
Are headaches new or has
their pattern changed within
the last 2 years?
Did the headache begin after a head
injury or is the headache associated with
a medical illness or intracranial
pathology or device (e.g., shunt)?
NO
NO
Does the patient regularly use
headache-relieving drugs or pain
medications >3 days per week?
NO
Diagnose probable medication overuse
headache. Headache diagnosis will need to
be re-assessed after overuse is resolved.
IF CONSTANT
How long does your typical
headache episode last?
SHORT DURATION
<2 HOURS
Consider cluster headache.
Verify excruciating,
unilateral, retro- or periorbital pain.
Diagnose as post-trauma
headache or headache related
to the primary illness
YES
Is the headache constant or
intermittent?
IF INTERMITTENT
YES
Review medications to ensure no
overuse. Then diagnose as tension-type.
LONG DURATION
≥2 HOURS
Are migraine features present: Either
A or a combination of B and C
A. Aura
B. 2 of these 4
• Unilateral pain
• Throbbing pain
• Activities restricted
• Pain worse with walking
steps or bending forward
C. Either of these 2
• Nausea
• Photophobia plus
phonophobia
Diagnose migraine.
YES
NO
Diagnose
tension-type.
Fig. 4 Headache diagnostic algorithm (reproduced with permission from Marcus [45])
medication [10]. Tension-type headache is a mild, constant or intermittent, nondisabling headache in patients without medication overuse. Cluster headache is
a relatively rare headache, characterized by typically nocturnal episodes of brief,
excruciating orbital or periorbital pain.
Migraine
Migraine is diagnosed in patients with chronic, recurring, intermittent, disabling
headaches who have characteristic associated symptoms [11]. Migraine should not