How Doctors Diagnose Headaches

The Questions Your Doctor Will Ask You to Evaluate Your Headache.

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Imagine a lifetime of intermittent headaches. You decide to finally see a physician after years of taking various over-the-counter and herbal headache relievers, seeking the advice of friends and family, and pouring over the internet. You wonder what your doctor will ask you that you have not sought out the answer to yourself. You decide to be prepared to tell your "headache story" in detail, so that a proper diagnosis and treatment plan can be initiated.

When evaluating your headache, your doctor will perform a detailed history and physical examination. This is done in order to make an accurate diagnosis, as well as to rule out headache warning signs

Questions During a Headache Evaluation

When evaluating your headache, your doctor will first likely ask you several specific questions about your headache, in order to narrow down the diagnosis. These questions include:

  • Character: “How would you describe your headache?" (e.g. throbbing, aching, burning or sharp)
  • Severity:  “What is your pain on a scale of 1 to 10, 10 being the worst pain of your life?” "Would you describe your headache as mild, moderate, or severe?" "Is this the worst headache of your life?"
  • Exacerbating or Alleviating factors: “What makes the pain better or worse?”
  • Radiation: “Does the pain radiate?” 
  • Onset: “Was the onset of your head pain rapid or gradual?"
  • Duration: “How long has the pain been going on for?" "Is the pain constant or intermittent?”
  • Associations: “Are there other symptoms associated with your headache?" (e.g. nausea, vomiting, visual changes)
  • Location: “Where is the pain located?”

In addition to these questions, your healthcare provider will also make note of your personal and family medical history, any medications you are taking, and your social habits (e.g. caffeine intake, alcohol use, smoking).

Based on your answers to the above questiona, your healthcare provider can decide whether or not your headache is a type of primary headache disorder. Let's take a closer look at the typical characteristics of the three most common primary headache disorders: migraines, tension-type headaches, and cluster headaches.

Diagnosing Migraines

Migraines are more than just headaches. A migraine is a common, neurologic condition that may or may not be associated with a migraine aura, a disturbance that classically causes visual symptoms, but also may include other neurologic symptoms, like sensory or speech alterations.

  • Character: Throbbing, pulsating
  • Severity: Moderate or severe
  • Exacerbating or Alleviating factors: Bright lights or loud noises may be exacerbating while NSAIDs, triptans and sleep are common migraine alleviators.
  • Radiation: Variable
  • Onset: Gradual (although usually not as gradual of onset as that of a tension-type headache).
  • Duration: 4-72 hours
  • Associations: Nausea, vomiting, phonophobia, photophobia, migraine aura (up to 1/3 of migraineurs)
  • Location: Unilateral (typically)

Diagnosing Tension-Type Headaches

Tension-type headaches are unique from migraines in that they are usually bilateral, non-pulsating, are not exacerbated by routine physical activity and are not associated with nausea or auras. On the other hand, migraines and tension-type headaches can both be associated with photophobia or phonophobia. Please note that according to the criteria created by the second edition of the International Classification of Headache Disorders (ICD-II), tension-type headaches can only be associated with either photophobia or phonophobia, not both. Frequent tension-type headaches often coexist with migraines without auras so maintaining a headache diary is critical, as treatment for these conditions is distinct.

  • Character: Pressing, tightening, "rubber-band-like sensation" around the head
  • Severity: Mild to moderate
  • Exacerbating or Alleviating factors: Usually alleviated with over-the-counter analgesics, like acetaminophen or NSAIDs. Smoking is one potential exacerbating factor, especially for those suffering from chronic tension-type headaches.
  • Radiation: Variable but commonly patients describe the pain as radiating from the back of the head into their neck muscles.
  • Onset: Gradual (usually a more gradual onset than that of a migraine)
  • Duration: Minutes to days (30 minutes to 7 days according to criteria from the International Headache Society)
  • Associations: No nausea but may be associated with either photophobia or phonophobia
  • Location: Bilateral

Diagnosing Cluster Headaches

A cluster headache, also known as a “suicide headache,” due to its SEVERE, debilitating intensity, plagues men more than women. These headaches occur in clusters or periods of time that typically last from one week to one year followed by pain-free periods of at least one month. During an episodic cluster headache, the sufferer can experience multiple attacks, typically up to eight daily. Some individuals suffer from chronic cluster headaches, in which a cluster headache period will last for more than one year without any pain-free periods, or pain-free periods that are less than one month.

  • Character: Sharp, burning, piercing
  • Severity: Severe to very severe
  • Exacerbating or Alleviating factors: Alcohol, histamine and nitroglycerin are examples of exacerbating factors, especially in chronic cluster headaches. Triptans and oxygen are potential acute therapies for cluster headaches.
  • Radiation: Variable
  • Onset: Rapid
  • Duration: If untreated, lasts 15-80 minutes, according to criteria from the International Headache Society.
  • Associations: Associated with autonomic symptoms including: ipsilateral or same-sided conjunctival injection and/or eye tearing, nasal congestion and/or discharge, eyelid swelling, forehead and facial sweating, miosis and/or ptosis, and agitation and/or restlessness.
  • Location: Strictly unilateral and either orbital or supraorbital (around the eye) or temporal.

The Bottom Line

When assessing your headache disorder, your doctor will likely ask you several of the above questions in order to best understand your symptoms. It may be a good idea to even write down answers prior to your visit, so you are best prepared.

Additionally, other tools your doctor may use in diagnosing your headache include the POUND mnemonic or the ID Migraine Questionnaire. Try to be thorough and proactive when evaluating your own headaches, so that together you and your doctor can create an effective treatment plan.


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DISCLAIMER: The information in this site is for informational purposes only. It should not be used as a substitute for personal care by a licensed physician. Please see your doctor for advice, diagnosis, and treatment of any concerning symptoms or medical condition.

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