Headache fact file - Part 2 - Headache tests and investigation

The second of this five-part series is on examining and investigating headaches.

Testing the plantar reflex as part of a standard neurological examination of a headache patient

Headache history

  • How many different types of headache do you get? Patients can identify separate headaches. Examine each one in turn.
  • Time questions: why are they consulting now? How recent is the onset? The temporal pattern?
  • Character questions: intensity; nature and quality; sight; associated symptoms (particularly nausea, phonophobia, photophobia, movement sensitivity).
  • Cause questions: predisposing or trigger factors; family history of similar headache.
  • Response questions: what do you do when you get a headache? (tension-type headache - keeps going; migraine - wants to lie down; cluster headache - wants to bang their head against a wall). What medication has been and is being used?
  • State of health between attacks. Concerns, comorbid anxiety or depression.
What do patients want?
  • To be taken seriously by a sympathetic doctor.
  • To have their ideas, concerns and expectations explored.
  • To have their problem explained in terms they understand.
  • To be offered informed choice about treatment with a clear management plan.
  • Not to be abandoned - follow up is important.

The headache examination
Fundoscopy and BP measurements are minimal. The examination box shows a simple examination pro forma excluding most pathologies. Subtle neurological nuances are rarely helpful in the examination.

Headache diaries are invariably useful. Scores, such as the migraine disability assessment and the headache impact test, can assess impact and monitor treatment.

Blood tests
Primary investigations:

  • FBC - anaemia, leukaemia and infection can cause headache.
  • Thrombocytopaenia.
  • ESR and CRP - if raised can indicate temporal arteritis or systemic disease.
  • Creatinine - renal failure can cause headache.
  • Calcium - to exclude hypercalcaemia.
  • TFT - headache can be associated with hypothyroidism.
  • LFT - could indicate metastatic disease.
  • Carbon monoxide level where relevant.

Secondary investigations:

  • Venereal disease research laboratory (syphilis) test.
  • HIV.
  • Lyme antibodies.
  • Antinuclear antibodies, lupus anticoagulant, anticardiolipin antibodies.


  • CT is more accurate for haemorrhage up to five days after the event but will miss around 10 per cent of space- occupying lesions, especially in the posterior fossa.
  • Ten per cent of patients will experience problems with claustrophobia with MRI.
  • Three per cent will show incidental abnormalities, which invariably give cause for unnecessary concern.

Red flags
Red flags signify presentations where the probability of an underlying tumour is likely to be greater than 1 per cent. These warrant urgent investigation. Headache with:

  • Papilloedema or focal neurological signs.
  • Alterations in consciousness, memory or co-ordination.
  • New-onset cluster headache (imaging, particularly of the region of the pituitary fossa, required but non-urgent).
  • A history of cancer elsewhere particularly breast and lung.

Orange flags
Orange flags occur in presentations where the probability of an underlying tumour is between 0.1 and 1 per cent. These need careful monitoring and a low threshold for investigation.


  • Where a diagnostic pattern has not emerged after eight weeks from presentation.
  • Aggravated by exertion or valsalva manoeuvre.
  • Has been present for some time but has changed significantly, particularly a rapid increase in frequency.
  • Wakes the patient from sleep.
  • New headache in the over 50s.

Dr Kernick is a GP in Exeter, Devon, and RCGP headache clinical champion

Risks of headache associated with a tumour

  • Annual incidence in population - six to 10 per 100,000.
  • Headache presentation to GP - one in 1,000.
  • Headache presentation to GP if migraine or tension-type headache can be diagnosed - one in 2,000.
  • Risk of tumour in isolated headache where diagnosis cannot be made after eight weeks - approximately 0.8 in 100.
  • Risk of discovering incidental abnormality on investigation - 0.6 to 10 in 100, depending on age.
  • Suggested risk of tumour at which investigation should take place - one in 100.



A simple pro forma for a headache examination

  • Pupillary responses and fundoscopy.
  • Visual fields.
  • Eye movements (superior, inferior, lateral).
  • Facial movements (wrinkle forehead, grimace with teeth).
  • Protrude tongue.
  • Outstretch arms, palms upwards for palmar drift.
  • With eyes closed, touch nose with finger (upper limb pyramidal, posterior column).
  • Finger dexterity (play piano).
  • Rapid hand movement, tap fingers of one hand on opposite palm and vice versa (cerebellar co-ordination).
  • Limb and plantar reflexes.
  • Standing - feet together and eyes closed for balance (Romberg's test).
  • Walk heel to toe along a straight line.
  • Walk on heels, walk on toes.
  • Check for trigger points particularly over occiput, posterior neck and upper shoulders.
  • Active neck movement (rotation, lateral flexion).
  • In the acute setting, include temperature and look for rash, neck stiffness and temporal artery tenderness if over 50.


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