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  • Consensus article
  • Open Access

European headache federation consensus on technical investigation for primary headache disorders

  • 1Email author,
  • 2,
  • 3,
  • 4,
  • 5,
  • 6,
  • 7,
  • 8,
  • 9,
  • 10,
  • 11,
  • 12,
  • 13 and
The Journal of Headache and PainOfficial Journal of the "European Headache Federation" and of "Lifting The Burden - The Global Campaign against Headache"201617:5

  • Received: 16 January 2016
  • Accepted: 2 February 2016
  • Published:


The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.


  • Primary headache disorders
  • Migraine
  • Tension-type headache
  • TACs
  • Consensus
  • Diagnostic tests
  • Brain MRI

Main text

Headache is a symptom in the main rather a condition. Only when headache attacks fulfill specific diagnostic criteria consistently does a primary headache disorder occur [1]. Accompanying symptoms are important together with the particular headache characteristics including pain severity, duration, quality and location. In most cases headache is primary but secondary headache disorders may be related to life threatening conditions. They may respond to common analgesics and mimic primary ones a lot. Diagnostic tests are necessary therefore when the treating physician doubts for the primary origin of headache. Up-to-date there is no official recommendation for these tests, although headache remains the commonest presenting symptom in people asking medical consultation. To bridge this gap European Headache Federation (EHF) appointed an internal and external committee to prepare a consensus on the diagnostic testing that primary headache disorders may require. The procedure followed was consisted of three phases. In phase one members of the Executive Board of EHF (internal committee: DDM, AS, CL, KP, VO and PM) prepared the first draft that was send to all National European Headache Societies for review. Thirteen National Headache Societies replied (40 %) with comments. European Headache Alliance also participated in this review phase. Based on their comments and suggestions draft 2 was edited (phase 2) that was applied for review in a group of distinguished headache specialists that EHF appointed as the external subcommittee (MA, HCD, MDF, PJG, JP, and JO). After fulfilling all comments into one manuscript the final draft of the consensus was arranged (phase 3), which is presented in the Appendix. Table 1 summarizes the principles.
Table 1

Tests recommended for primary headache disorders

ICHD-IIIb code







Migraine without aura



Frequent episodic migraine

Brain MRIa

Carodit ultrasound or MRAa



Migraine with aura

Brain MRIa


Migraine with brainstem aura

Brain MRI & MRA


Carotid and vertebral arteries ultrasound/or CT or MRAa

Genetic evaluationa


Chronic migraine

Brain MRI Gd & MRVa


Lumbar puncturea



Complications of migraine

Brain MRI


Persistence of aura symptoms

Emergency brain CT or MRI

Carotid and vertebral arteries ultrasound/or CT or MRA



Migrainous infarction

Emergency brain CT or MRI

Carotid and vertebral arteries ultrasound/or CT or MRAa



Migraine aura-triggered seizures

Repetitive EEGs or video EEG


Probable migraine

Brain MRIa


Episodic syndromes that may be associated with migraine

Gastric work-up





Infrequent TTH


2.2 and 3

Frequent TTH and Chronic TTH

Brain MRI MRI Gd & MRVa


Lumbar puncturea



TACs (all)

Brain MRI

Brain MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa

Pituitary function testinga


Cluster headache



Paraxysmal Hemicrania

Brain MRI and MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa


Suna & Sunct

+ High resolution MRI of brainstem


Hemicrania Continua

Brain MRI

Brain MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa


Other primary headache disorders



Primary cough headache

Brain MRI

Cranio-cervical and brain MRAa


Primary exercise headache

Brain MRI and MRA/MRV

Lumbar puncturea

Carotid & vertebral ultrasound, or CT or MRA

Cardiological evaluation a


Primary headache associated with sexual activity


Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea



Primary thunderclap headache


Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea



Cold-stimulus headache



External-pressure headache



Primary stabbing headache


Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea



Nummular headache

Brain MRI, ESR, ANF and RF


Hypnic headache



24-hour blood pressure monitoring


New daily persistent headache

Brain MRI, MRA

Lumbar puncturea

aIndicates specific conditions


EHF committee

1. Bendtsen, Lars (Danish Headache Society);

2. Bicakci, Sebnem (Turkish Neurological Society Headache Chapter and Headache and Pain Research Society);

3. Braschinsky, Mark (Estonian Headache Society);

4. Brossner, Gregor (Austrian Headache Society);

5. Constantinidis, Theodoros (Hellenic Headache Society);

6. Costa, Cinzia (Italian Headache Society);

7. Edvinsson, Lars (Swedish Migraine Society);

8. Freimane, Aija (Latvian Association for the Study of Pain);

9. Gantenbein, Andy (Swiss Headache Society);

10. Gouveia, Raquel Gil (Portuguese Headache Society);

11. Groseva, Veselina (Bulgarian Headache Society);

12. Hristova, Sonya (Bulgarian Headache Society);

13. Karli, Necdet (Turkish Neurological Society Headache Chapter and Headache and Pain Research Society);

14. Latysheva, Nina (Russian Headache Society);

15. Ljubisavljevic, Srdjan (Serbian Headache Society);

16. Logina, Inara (Latvian Association for the Study of Pain);

17. Milanov, Ivan (Bulgarian Headache Society);

18. Obelleniene, Diana (Lithuanian Headache Association);

19. Palavra, Filipe (Portuguese Headache Society);

20. Parreira, Elsa (Portuguese Headache Society);

21. Riederer, Franz (Austrian Headache Society);

22. Sacco, Simona (Italian Headache Society);

23. Schytz, Henrik (Danish Headache Society);

24. Sergeev, Alexey (Russian Headache Society);

25. Steinber, Anna (Swedish Migraine Society);

26. Toom, Kati (Estonian Headache Society);

27. Vikelis, Michail (Hellenic Headache Society);

28. Zebenholzer, Karin (Austrian Headache Society);

29. Zidvec-Trajkovic, Jasna (Serbian Headache Society).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

Neurology Department, Athens Naval Hospital, Athens, Greece
Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
European Headache Alliance, President, Dublin, Ireland
Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, and King’s Clinical Research Facility, Kings College London, Wellcome Foundation Building, King’s College Hospital, London, SE5 9PJ, UK
Center for Proteomics and Metabolomics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
Medical Headache Center, Hospital Sisters of Mercy, Seilerstaette Linz, Linz, 4020, Austria
Department of Neurology, Ghent University Hospital, Ghent, Belgium
University Hospital Marqués de Valdecilla and IDIVAL, 39011 Santander, Spain
Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Millet Cad, 34390 Capa/Istanbul, Turkey
Danish Headache Centre and Department of Neurology, Rigshospitalet, Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
Department of Neurology, First Moscow State Medical University, Moscow, Russia
Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy


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© Mitsikostas et al. 2016


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