“Neurology Cleared the Patient” Is Not a Psychiatric Diagnosis

A negative neurologic evaluation may narrow the differential. It does not establish anxiety, depression, somatic symptom disorder, or functional neurological disorder.

The patient below is a fictional composite. No individual is depicted. The article does not determine her diagnosis, and it does not tell anyone what to order.

She is 34. Her second child is four months old. The headaches began about six weeks after delivery and have been daily for ten weeks: a dull, whole-head pressure that is there when she wakes and worse by evening. She is exhausted in a way that sleep does not fix, though her sleep is broken anyway. She has stopped driving because she does not trust her concentration.

Her first visit was to primary care. The postpartum depression screen was positive. She left with a prescription for an SSRI. The note attributed the headache to tension and sleep deprivation but did not document a primary headache diagnosis. A CBC, a metabolic panel, and a TSH were normal.

Her second visit was to an emergency department, on a night the headache frightened her. A noncontrast head CT was normal. She was discharged with "headache, unspecified."

Her third visit was to neurology. The examination was normal. An MRI of the brain was normal. The note reads: "No neurologic cause identified. Likely psychiatric. Recommend psychiatry for mood and sleep."

Two things are in the chart that are not in any physician's note. The emergency department triage nurse wrote that her vision "goes dark for a few seconds" when she stands up. It appears in the nursing assessment and nowhere else. And there is a portal message, sent the week after the neurology visit, in which she asks whether it matters that the headache is different from the ones she used to get. It has not been answered.

She arrives in a psychiatry clinic with the neurology sentence as her referral reason and three months of normal results behind it.

The referral contains a conclusion. Read it as two clinical statements, because that is what it is:

"We did not identify a structural neurologic cause."

"The symptom is caused by a psychiatric disorder."

The first is a fact about tests that were performed. It is true, it is documented, and it is worth knowing. The second is a diagnosis. It requires positive evidence that a psychiatric disorder is present and that the disorder accounts for the symptom. Nobody collected that evidence. The referral moves from the first statement to the second without an act in between, and the psychiatrist receives the second statement as if it had been established somewhere upstream.

A negative test is a fact about the test. The CBC, metabolic panel, and TSH answered the questions they were ordered to answer. A normal result does not extend to questions nobody ordered.

Migraine and tension-type headache are diagnosed clinically. They are diagnosed on the pattern of the headache and the absence of features that point elsewhere, not on imaging. The American Headache Society's 2020 guideline states that neuroimaging is not necessary in patients with headache consistent with migraine, a normal neurologic examination, and no atypical features or red flags. The point is not that imaging is useless. The point is that a normal scan was never how a primary headache disorder gets diagnosed, so a normal scan cannot be the reason a primary headache diagnosis was never made.

The NICE headache guideline, CG150, says the same thing from the other direction. It recommends against referring people already diagnosed with tension-type headache, migraine, cluster headache, or medication overuse headache for neuroimaging solely for reassurance, and it recommends that the discussion with the patient include a positive diagnosis and recognition that headache is a valid medical disorder.

The patient in the vignette never received a positive headache diagnosis. She received the absence of a structural one. Those are different outputs, and the second does not substitute for the first. The International Classification of Headache Disorders builds the distinction into its criteria: a primary headache diagnosis is made on its own features and on the requirement that the headache is "not better accounted for by another ICHD-3 diagnosis." That is a diagnostic act. "No neurologic cause identified" is not one.

Every test in the vignette answered a narrow question. The missing-acts chain is the list of questions it did not answer.

The noncontrast CT and the routine MRI establish that no structural lesion was seen on those sequences. Neither the noncontrast CT nor the routine MRI documented in this vignette establishes that dedicated venous imaging was performed. For a patient whose headache began in the first 6 weeks after delivery, that is not an incidental gap. The 2024 American Heart Association scientific statement on cerebral venous thrombosis lists pregnancy and the postpartum period among the established risk factors and describes diagnosis as resting primarily on MRI with MR venography or CT with CT venography. The article is not saying she has a venous thrombosis. It is saying that the chart does not show the question was asked.

The laboratory panel establishes that three common values were in range on one date. It does not establish that medication effects, sleep, substances, or systemic illness were reconciled against the symptom.

The neurologic examination establishes that it was normal on the day it was performed. It does not carry forward the nursing note about transient darkening of vision on standing, because that note never reached a physician.

The referral establishes that neurology considered its evaluation complete. It does not establish what "complete" contained.

Ask of each result: what question was this ordered to answer, and what does a normal answer leave open? That is the whole method.

Each visit in the vignette inherited the previous visit's conclusion as evidence. Primary care attributed it to tension and sleep deprivation, and that became the prior the emergency physician started from. The normal CT became the prior neurology started from. The normal MRI became the referral. At no point did anyone re-ask the original question. Each clinician narrowed it, honestly and defensibly, on the assumption that the last clinician had done the wider work.

Three normal results are not one exclusion. They are three separate answers to three narrow questions, stacked in a way that looks like breadth.

The psychiatrist is the fourth clinician, and the first asked to convert an incomplete exclusion into a causal diagnosis. The handoff is written as though psychiatry were the endpoint. It is not. Psychiatry can reopen the medical evaluation, return the patient for the specific assessment that was never documented, or decline to record a causal psychiatric diagnosis until the exclusion is actually complete. The pressure of the handoff is real. The obligation it implies is not.

Major depressive disorder, generalized anxiety disorder, and the other diagnoses that the referral implies are all defined by positive criteria: symptom clusters, duration, functional impact, and exclusions of their own. The psychiatric evaluation can establish that those criteria are met. It can also establish that they are not. What it cannot do is make a diagnosis out of the absence of somebody else's findings.

Two diagnoses deserve a specific note, because they are the ones most often reached for when a workup is negative.

Somatic symptom disorder is defined by excessive thoughts, feelings, or behaviors related to a symptom, not by the symptom being medically unexplained. It can coexist with an identified medical condition, and its presence is not evidence that the symptom is psychiatrically caused.

"Functional" is also a positive diagnosis. Functional neurological disorder is made on findings that are present, not on findings that are absent, and the specific signs that support it concern particular motor and sensory phenomena. It is not a synonym for "tests negative," and it does not resolve a persistent headache.

A postpartum depression screen was positive in the vignette. That is a real finding and it deserves a real evaluation. It is also a screen. A positive screen is a reason to assess, not a completed assessment; the ACOG clinical practice guideline on perinatal mental health screening distinguishes screening from diagnostic evaluation. A positive screen does not explain a new daily headache that began six weeks after delivery.

A patient can have migraine and depression. A patient can have sleep apnea and anxiety. A patient can have a postpartum mood disorder and a headache disorder that has nothing to do with it. Coexistence does not assign direction, and finding one condition does not close the question of the other.

The trap in the vignette is that the psychiatric finding is real and the medical question is open at the same time. The referral resolves the tension by letting the real finding explain everything. The clinician's job is to hold both: treat what is established, and decline to let it stand in for what is not. "Unexplained" is a status. It is not the same word as "imagined," and it should not be documented as if it were.

Before recording a psychiatric diagnosis as the cause of a symptom that arrived with a negative workup:

The absence of a neurologic explanation may justify a psychiatric evaluation. It does not dictate the result of that evaluation.

The companion worksheet asks the reader to mark each of the following as Present, Absent, or Unknown in the chart. A Present or Unknown finding on item 1 or item 3 means the handoff does not document a completed exclusion. What follows is clinical judgment. Do not carry a causal psychiatric attribution forward without independent support.

Worksheet: "Negative Workup" Handoff Record, one page plus recap, house blue. Fillable fields deferred to v2.

Primary sources consulted for this article, with the date each was reviewed.

1. International Classification of Headache Disorders, 3rd edition (ICHD-3). International Headache Society, ichd-3.org. Criterion quoted: "not better accounted for by another ICHD-3 diagnosis." Confirmed as criterion E of 1.1 Migraine without aura; the same phrase is a recurring final criterion across ICHD-3 entries. Reviewed August 28, 2026.

2. NICE. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. Published 19 September 2012; last updated 3 June 2025. nice.org.uk/guidance/cg150. Used: recommendation 1.3.3 against neuroimaging solely for reassurance; recommendation 1.3.4 that discussion include a positive diagnosis and recognition of headache as a valid medical disorder. Reviewed August 28, 2026.

3. Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache. 2020;60(2):318-336. doi:10.1111/head.13720. PMID 31891197. Used: Grade A recommendation that neuroimaging is not necessary in headache consistent with migraine with normal neurologic examination and no atypical features or red flags. Reviewed August 28, 2026.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2022. Somatic symptom disorder, diagnostic criteria and diagnostic features; major depressive disorder and generalized anxiety disorder, diagnostic criteria. Reviewed August 28, 2026.

5. Espay AJ, Aybek S, Carson A, et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol. 2018;75(9):1132–1141. doi:10.1001/jamaneurol.2018.1264. PMID 29868890. Used: FND is diagnosed on findings that are present, not absent; positive signs concern particular motor and sensory phenomena. Reviewed August 28, 2026.

6. Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association. Stroke. 2024;55:e77–e90. doi:10.1161/STR.0000000000000456. PMID 38284265. Used: pregnancy/puerperium among major risk factors; diagnosis primarily by MRI/MR venography or CT/CT venography; greatest risk periods include the third trimester and the first 6 postpartum weeks (covers onset at six weeks after delivery). Not used: incidence figures, symptom frequencies, treatment recommendations. Reviewed August 28, 2026.

7. American College of Obstetricians and Gynecologists. Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum. Clinical Practice Guideline No. 4. June 2023. Obstet Gynecol. 2023;141(6):1232–1261. doi:10.1097/AOG.0000000000005200. Used: distinction between screening and diagnostic evaluation for a positive perinatal depression screen. Reviewed August 28, 2026.

Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Requirements and appropriate practices may vary by jurisdiction and circumstance. Verify current authoritative sources. This article is not a headache evaluation protocol and does not recommend any specific test. The patient described is a fictional composite; no individual is depicted.