Headache (Cephalgia): Diagnostic Tests

Optional medical device diagnostics – depending on the results of the history, physical examination, laboratory diagnostics, and obligatory medical device diagnostics – for differential diagnostic workup

• Magnetic resonance imaging of the skull (cranial MRI, cranial MRI or cMRI) – for suspected parenchymatous changes as well as abnormalities; furthermore, for:
  • For initial diagnosis, in the case of conspicuous neurological examination or in older patients (> 60th LJ) useful to exclude neurological clinical pictures such as destructive bone processes, brain tumors or vascular malformations.
  • Atypical headache
  • Recent changes in the pattern of pain
  • Suspected: autoimmune CNS disorders; bridging vein thrombosis; brain metastases; pituitary apoplexy; cerebrospinal fluid hypotension syndrome; infectious CNS disorders; reversible cerebral vasoconstriction syndrome (RCVS); subarachnoid hemorrhage.
  • Symptoms such as epileptic seizures, as well as focal neurologic complaints or signs
  • Pregnant women (see below “Further notes”).
• Computed tomography of the skull (cranial CT, cranial CT or cCT) – if suspected:
  • Dissection (splitting of vessel wall layers) of the vessels supplying the brain.
  • Intracerebral hemorrhage (ICB; cerebral hemorrhage).
  • Ischemic apoplexy (stroke)
  • Sinus vein thrombosis (SVT; occlusion of a cerebral sinus (large venous blood vessels of the brain arising from duraduplications) by a thrombus (blood clot)).
  • Subarachnoid hemorrhage (SAB; bleeding between the spinal meninges and the soft meninges).
  • Bony lesions
• Angio-CT or angio-MRI – if sinus vein thrombosis is suspected.
• Digital subtraction angiography (DSA; procedure for isolated imaging of vessels) – in suspected aneurysms (arterial dilation) or vasculitides (diseases in which autoimmunological processes lead to inflammation of arteries, arterioles and capillaries).
• Extracranial Doppler sonography/duplex sonography (ultrasound examination: combination of a sonographic cross-sectional image (B-scan) and the Doppler sonography method; medical imaging technique that can dynamically visualize fluid flows (especially blood flow)); indications:
  • Suspected dissection of brain-supplying vessels (note: MRI with fat-suppressed sequences more sensitive).
  • Carotid artery [halo sign in carotid artery is relatively specific for Takayasu arteritis]
  • Suspicion of arteritis: examination of the temporal artery [halo sign in the temporal artery is relatively specific for arteritis cranialis] and, if necessary, biopsy (tissue sampling) of the temporal artery – Any new onset of headache after the age of 50, regardless of location
• Encephalogram (EEG; recording of the electrical activity of the brain) – if seizures are suspected.
• X-rays of the cervical spine – if vertebragene (spinal) cause of the headache is suspected.
• X-rays of the paranasal sinuses or computed tomography (CT; sectional imaging method (X-rays from different directions with computer-based evaluation)) of the paranasal sinuses – if sinusitis (sinusitis) is suspected.
• Neurophysiological examinations – if neuritis (inflammation of the nerves) is suspected.
• Polysomnography (sleep laboratory; measurement of various bodily functions during sleep, which provide information about the quality of sleep) – if sleep apnea syndrome is suspected (symptom caused by respiratory arrest (apnea) during sleep).

Further notes

• In children with localized headache and no neurologic abnormalities (292 children; at least five attacks of pain), 96% of MRI examinations yielded normal findings. MRI revealed abnormalities in 4% of children, but these were exclusively nonspecific incidental findings and did not require surgical intervention.
• Pregnant women with acute headache (number of cases: 151): imaging examination revealed:
  • Normal findings in 59 percent of pregnant women
  • Incidental findings unrelated to the headache in 14 percent
  • Symptom-related pathologic findings in 28 percent; incidence was highest in the 1st. Trimester (third trimester of pregnancy) highest; 6 cases of intracranial hemorrhage (cerebral hemorrhage); 5 women with cerebral venous thrombosis (formation of a blood clot (thrombosis) in a cerebral vein), 4 with posterior reversible encephalopathy syndrome (PRES), 3 with acute cerebral infarcts, 3 with acute sinusitis (sinusitis); predictors of these findings were at all stages of pregnancy: Severe pain intensity, reduced consciousness, and seizures.