Diagnosing Headache

For many people, headaches are merely an occasional nuisance. But for some, headaches may have a profound impact on their lives. Many headaches can be relieved using over-the-counter medication. If your headaches become severe, NYU Langone doctors can provide you with the best and most effective treatment plan.

Our experts, including neurologists specially trained in headache medicine, work together with specialists such as otolaryngologists, endocrinologists, neuro-ophthalmologists, internists, gynecologists, pain medicine doctors, physical medicine specialists, psychologists, psychiatrists, neuroradiologists, and neurosurgeons to identify and alleviate sources of pain and to develop an interdisciplinary treatment plan.

Headaches are divided into two categories: primary and secondary. Primary headaches are not caused by an underlying health condition or structural problems in the brain, head, or neck.

Secondary headaches are more rare and are caused by an injury or other medical conditions such as an infection, tumor, stroke, or aneurysm.

Types of Headache

The three major types of primary headaches are tension-type, migraine, and cluster headaches. All three cause pain, although the type and severity of this pain varies.

Tension-Type Headaches

Tension-type headaches may cause dull pressure or constant, tight, vise-like sensations in the head, scalp, or neck. Pain is usually mild to moderate and is distributed equally around the head.

These headaches can be triggered by stress, lack of sleep, hunger, or activities that require staying in one position for too long, such as using a computer or reading.

Tension-type headaches are the most common kind of headache and are slightly more prevalent in women than in men. They are often episodic but can evolve into a chronic condition.

Migraines

A migraine is a debilitating, recurrent type of headache that causes moderate to severe throbbing pain on one or both sides of the head. Migraine is more than just a headache. Attacks of pain are often accompanied by nausea, vomiting, and a heightened sensitivity to light, sounds, or odors. Approximately 20 percent of people with migraine experience visual or other neurologic symptoms prior to the onset of the headache, which may cause sensitivity to light and sound as well as nausea or vomiting.

The condition is a common, often disabling disease that affects approximately 36 million Americans. Migraine can be chronic, meaning they occur 15 or more days per month over a 3-month time span, or episodic, meaning they occur fewer than 15 days per month.

Migraine pain typically builds up for a few hours and may intensify with movement or physical activity. Migraine can last anywhere from four hours to several days if not treated.

People who experience migraine tend to have recurring attacks that can be triggered by a variety of factors, such as anxiety, stress, hormonal changes, bright or flashing lights, and certain foods or drinks.

Cluster Headaches

Cluster headaches cause severe, stabbing pain located around one eye or in the temples. These episodic headaches commonly happen around the same time every day, often near bedtime or after you go to sleep.

They may occur for several weeks or months at a time. People who experience one of these headache episodes may not have symptoms again for several months or even years.

This type of headache tends to pass more quickly than a migraine, but is more intense. Cluster headaches are less common than tension-type headaches and migraines.

They may cause redness and tearing of one eye, nasal congestion, or a droopy eyelid, and the pupil may change size. Cluster headaches occur more frequently in men and young adults.

Your First Visit

To determine the type of headache causing your pain, neurologists at NYU Langone ask about your headache history and symptoms, focusing on the frequency, intensity, duration, location, and any known triggers. Your doctor also conducts a comprehensive review of your medical history and family history of headache and performs a physical exam to obtain a complete picture of your health. To help the doctor make a more accurate diagnosis, bring to your appointment past medical records, including imaging scans and reports, and any lab studies you might have had.

Relying on over-the-counter pain medication to treat chronic headaches can lead to overuse of these medications, which, over time, can make headaches worse and unresponsive to treatment, even when the medications are used as directed. Providing your doctor with a list of your current medications, including supplements, vitamins, and over-the-counter treatments, the doses, and length of time you used them, can help to ensure you are not experiencing headaches from medication overuse.

Preparing for Your Appointment

Keeping a journal to track your headache frequency and duration can help your doctor make a diagnosis. Your doctor may ask you the following questions:

• Where is the pain located? Is it one-sided? Which side is involved?
• What does the pain feels like? Is it pounding, throbbing, stabbing, steady ache, or pressure?
• How severe is the pain on a scale of 1 to 10?
• How often do the attacks occur?
• How long do attacks last (with and without treatment)?
• What symptoms accompany the pain? Do you have nausea, vomiting, numbness, weakness, sensitivity to light or sound or smells, dizziness, tearing, drooping of an eyelid, congestion, or discharge from one nostril?
• Are there factors that bring headaches on, such as weather changes, stress, sleep changes, missed meals, menstruation, exertion, or certain foods or alcohol?

It can also help to have a family member or close friend accompany you to the visit to help you recall certain details of your headache episodes.

Diagnostic Tests for Headache

Depending on your symptoms and the results of your medical and neurologic examinations, your physician may recommend further diagnostic testing. Your doctor may use one or more of the following tests to arrive at the most accurate diagnosis.

Neurological Exams

A neurological examination may include an evaluation of your mental status, motor strength, vision, and reflex testing. Your doctor may also assess the function of the nerves connected to the brainstem—the cranial nerves—by testing for sensation in the face, checking your hearing and eye movements, asking you to swallow or say “ahh,” and observing your ability to move your head, neck, and shoulders.

Your doctor may test your vision and look for any signs of increased pressure in your head. Your reflexes may also be checked to see whether the headaches are caused by a rarer problem, such as a brain tumor or blood clot in the brain, or to rule out the possibility that another condition may be causing your symptoms.

MRI Scans

MRI uses magnetic waves and computers to create two- or three-dimensional images. Your doctor may order an MRI scan to view the inside of the head and neck. This can reveal the presence of other conditions that can cause headaches, such as a tumor or abscess, which is a collection of pus that has formed in response to an infection.

Sometimes, MRI scans of the neck are used to identify problems with the cervical spine—the bones in the neck—that may be triggering headaches.

Magnetic Resonance Angiogram

A magnetic resonance angiogram, or MRA, is similar to an MRI scan. It’s an imaging technique that is used to check for an abnormality, such as an aneurysm, in the blood vessels of the brain.

The test may involve injecting dye into a blood vessel, so that your doctor can view blood flow in the arteries or veins of the head or neck. Some MRA scans can be done without the use of dye.

MRA scans allow your doctor to see if blood vessels are blocked by a clot or if there are any other factors that may be restricting or increasing blood flow and triggering the headaches.

NYU Langone specialists use the results of these tests, along with their clinical judgment and skills, to craft a treatment plan to alleviate your symptoms. If your doctor determines that your headaches are caused by a secondary condition, he or she may recommend that the underlying condition be treated first to see if this stops the headaches from occurring.

If you are diagnosed with primary headaches, our physicians can offer a variety of treatment options, including medications and a nerve block procedure, that may reduce or eliminate your symptoms.