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eadache is one of the most common reasons for a patient to see a doctor. While most patientshave a benign headache type, the headache can be theinitial presentation of a serious underlying illness. Infact, many patients harbour the fear they may have a brain tumour. It is important, therefore, that the physi-cian understand the possible etiologies of headache,as well as the clinical features suggestive of a seriousunderlying cause for headache.Headache diagnosis may also be difficult becausesome headache types are quite uncommon (

i.e.,

clus-ter headache), while others may appear superficiallyvery similar to each other (

i.e.,

those conditions thatresult in chronic daily headache). These factors canalso lead to uncertainty in headache diagnosis by thefamily physician.In this article, the author will review headacheclassification, some of the features which suggest aserious underlying cause for headache, and the diag-nostic features of some of the less common headachesyndromes.

Classifying Headaches

It has been said that a good classification makes order out of chaos. This is especially true for headache, and if a physician is unable to classify a patient’s headachedisorder, this leads to uncertainty with regard to diag-nosis and to treatment.The International Headache Society (IHS) hasworked hard to establish a comprehensiveheadache classification, which tries to group allheadache types into 13 overarching categories.

Each of these categories has many sub-categories,

The Canadian Journal of CME / February 2003

Focus on CME at theUniversity of Calgary

By Werner J. Becker, MD, FRCPC

Is this justa

Headache?

Case

A 25-year-old woman presents to your officecomplaining of headache. These headacheswere one day in duration, occurred about oncea month and were described as severe,throbbing, bilateral, and primarily occipital.There was associated nausea, phonophobiaand, at times, vomiting. At this stage, herheadaches were diagnosed as migraine. Shehad a normal neurologic examination, and herheadaches met diagnostic criteria for migrainewithout aura. They were purely occipital, whichis unusual, but can occur in a small percentageof patients with migraine. A variety ofsymptomatic and prophylactic migrainemedications were eventually tried.Eight months later, the patient had dailyheadaches, which were bilateral, occipital, andfrontal. She also complained of problems withnausea, even with no headache. Her headacheswould occasionally awaken her at night, wereworse in the mornings and when standing up.She complained of ringing in her right ear. Herneurologic examination remained normal,including her optic fundi.

Focus on CME at theUniversity of Toronto

CME Workshop

and detailed discussion of many of these is beyond the scope of this article.Migraine is the headache type that brings most patients to physicians, and it comes in many guises.Particularly problematic are patients who havemigraine aura without headache, as considerationmust be given to whether the patient has a transientischemic attack or perhaps a focal seizure. Migrainewith prolonged aura, where a migraine aura symptomgoes beyond the usual limit of 60 minutes, also caus-es concern with regard to cerebrovascular disease.All the headache types in the IHS headache classi-fication have diagnostic criteria. It is unrealistic toexpect the family practitioner to know all of these, butthe diagnostic criteria for migraine without aura areshown in Table 1. These diagnostic criteria make the point that the diagnosis of many headache syndromes,including migraine, is basically a clinical diagnosis.As for many other benign headache types, however,the final diagnostic criterion for migraine is that noother cause must be apparent. For the most part, aclinical examination, including a careful neurologicexamination, is sufficient to meet this diagnostic cri-terion. The point is that patients with headachedeserve a careful clinical examination.

When Should I Suspect ASerious Underlying Cause?

This is a difficult area, where a lot of clinical judg-ment and experience comes into play. One can list sixclinical features that should cause some concernabout a possible serious underlying cause for the patient’s headache. Again, none of these is diagnostic,and clinical discretion must be used as to how signif-icant any one of these is in any particular patient.Each of the clinical features shown in Table 2requires clinical interpretation and judgment. For example, although most patients who developmigraine will have done so by the age of 30, some patients develop migraine later in life. Also, patients with migraine do have their ups and downs, so their headache pattern may change eventhough no serious underlying cause for their headaches is present.

Headache

The Canadian Journal of CME / February 2003

Dr. Becker is professor and head,division of neurology, departmentof clinical neurosciences,University of Calgary, Calgary, Alberta.

Table 1

Diagnostic Criteria For MigraineWithout Aura

The patient must have had at least five attacksmeeting the diagnostic criteria below:

•For headaches that are untreated orunsuccessfully treated, headache duration shouldbe between four and 72 hours.•The headache should have at least two of thefollowing characteristics:- Unilateral location;- Pulsating quality;- Moderate or severe intensity; and- Aggravation by walking stairs or similarphysical activity.•During headache there should be at least one ofthe following:- Nausea and/or vomiting; and- Photophobia and phonophobia.•History, physical and neurologic examinations donot suggest another cause for the patient’sheadache.

Modified from Headache Classification Committee of theInternational Headache Society: Classification and diagnosticcriteria for headache disorders, cranial neuralgias, and facial pain.Cephalalgia 1988; 8(Suppl. 7):1-96.

Headache

The presence of other neurolog-ic symptoms, that might suggest astructural lesion (

i.e.,

seizures)should always be taken seriously.Symptoms may include, for example, the presence of nausea betweenheadache attacks at times when the patient is pain-free. Abnormal focalneurologic signs on examinationshould always be taken seriously.A rapidly progressive headachesyndrome, where the patient’sheadaches are increasing rapidly in severity and/or frequency, should also be taken seriously. This devel-opment may suggest an enlarging intracranial masslesion or the development of increased intracranial pressure.Finally, there are patients who have unusualheadaches, which simply do not meet diagnosticcriteria for migraine, tension-type, or cluster headache. Although such patients may well havenegative investigations, structural or metaboliccauses may need to be excluded. Once again, clin-ical judgment must be exercised.The fear of many patients is that they may be har- bouring a brain tumour. Patients may transmit thisconcern to their physicians and, for the physician to beable to reassure the patient, it is important the physi-cian have confidence in his or her clinical diagnosis.Such confidence is best gained by a careful historyand physical, and a knowledge of the clinical featuresof the benign headache syndromes. If neuroimagingis necessary, a brain computed tomography (CT) scanwithout contrast will usually suffice. It is not appro- priate, however, to image every patient with recurrentmigraine or tension-type headache.With regard to the issue of brain tumour and headache, the study by Vasquez-Barquero is instruc-tive.

These authors reviewed the presentation of alarge series of patients with brain tumours and found that, at the time of diagnosis, virtu-ally all patients with brain tumour had at least one other neurologicsymptom besides headache.Furthermore, although headachecould be the only symptom of the patient presenting with braintumour, in their series the longestduration of headache as the onlysymptom was 77 days. By thistime, other symptoms were also present. It is unlikely, therefore,that cases of recurrent or chronicheadache lasting for many months or years are caused by a brain tumour.

What the CT shows

As can been seen from the patient history and theclinical features listed in Table 2, this patient certain-ly merits neuroimaging from several standpoints. Sheclearly has a rapidly progressive headache syndrome

The Canadian Journal of CME / February 2003

Table 2

Clinical Signs To Consider A Possible Serious Underlying Cause

•Recent onset of a significant headache condition,especially after middle age.•A recent change in an established headachepattern.•The presence of other neurologic symptomsbesides headache (

i.e.,

seizures).•Abnormal neurologic signs on examination (

i.e.,

focal neurologic signs that cannot be explained byanother known neurologic condition).•A rapidly progressive headache syndrome.•The inability to classify a patient’s headaches intoone of the benign headache syndromes (

i.e.,

thepatient’s headaches do not meet diagnostic criteriafor one of migraine, tension-type or clusterheadache syndromes).

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