Headache history
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headache history taking clinical approach
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headache classification types primary secondary
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Here is a structured framework for taking a headache history:
Headache History
A thorough headache history is the cornerstone of diagnosis. The goal is to determine whether a primary (no underlying structural/systemic cause) or secondary (caused by another disorder) headache is present, and to identify any red flags requiring urgent evaluation. (Harrison's Principles of Internal Medicine, 21st Ed., p. 570; Management of Headache, p. 30)
1. Onset & Temporal Profile
| Question | Clinical Relevance |
|---|---|
| When did the headaches first begin? | Long-standing vs. new-onset pattern |
| Was the onset sudden or gradual? | Thunderclap onset (worst headache of life, peaks in <1 min) → subarachnoid hemorrhage until proven otherwise |
| How long does each episode last? | Distinguishes migraine, cluster, tension-type |
| How frequently do episodes occur? | Episodic vs. chronic (≥15 days/month) |
2. Character & Severity
- Location: Unilateral vs. bilateral; frontal, temporal, occipital, periorbital
- Quality: Throbbing/pulsatile (migraine), pressure/band-like (tension-type), stabbing/ice-pick (trigeminal autonomic cephalalgias), constant boring (cluster)
- Severity: 0–10 scale; is it the worst headache ever?
- Radiation: To neck, jaw, face, or eye
3. Associated Symptoms
| Symptom | Consider |
|---|---|
| Nausea/vomiting, photophobia, phonophobia | Migraine |
| Aura (visual, sensory, speech) | Migraine with aura |
| Lacrimation, ptosis, rhinorrhea, conjunctival injection | Cluster headache / TAC |
| Fever, neck stiffness, photophobia | Meningitis |
| Visual changes, jaw claudication, scalp tenderness | Giant cell arteritis (age >50) |
| Neurological deficits, seizures, confusion | Raised ICP, mass lesion, stroke |
| Postural variation (worse lying down, better standing) | Raised ICP, CSF leak |
4. Aggravating & Relieving Factors
- Worsened by: Valsalva, exertion, coughing, bending (consider raised ICP, Chiari)
- Worsened by: Light, sound, movement (migraine)
- Relieved by: Sleep, darkness, quiet (migraine); rest in dark vs. pacing (cluster = pacing)
- Triggered by: Stress, menstruation, foods, fasting, alcohol, sleep changes
5. Red Flag Features ("SNOOP4")
| Flag | Meaning |
|---|---|
| Systemic symptoms (fever, weight loss) | Infection, malignancy, vasculitis |
| Neurological signs or symptoms | Mass, hemorrhage, meningitis |
| Onset sudden/thunderclap | SAH |
| Older age of new onset (>50 yrs) | GCA, malignancy |
| Progressive worsening pattern | Mass lesion, raised ICP |
| Postural component | ICP change, CSF leak |
| Papilledema | Raised ICP |
| Precipitated by Valsalva/exertion/sex | SAH, posterior fossa lesion |
6. Past Medical & Medication History
- Prior headache diagnoses and treatments tried
- Medication overuse (analgesics/triptans ≥10–15 days/month → can cause chronic daily headache)
- Relevant conditions: HTN, head trauma, cancer, HIV/immunosuppression, pregnancy
- Family history of migraine
7. Primary vs. Secondary Distinction (ICHD-3)
A secondary headache is diagnosed when (Management of Headache, p. 30):
- The headache is new and develops in close temporal relation to a causative disorder, OR
- A preexisting headache significantly worsens in temporal relation to a causative disorder.
The main secondary headache categories include: vascular disorders, intracranial pathology, trauma, infection, substance/withdrawal, homeostatic disorders, and psychiatric disorders.
Summary: Key Primary Headache Features at a Glance
| Feature | Migraine | Tension-Type | Cluster |
|---|---|---|---|
| Location | Unilateral | Bilateral | Unilateral periorbital |
| Quality | Throbbing | Pressure/tightening | Boring/stabbing |
| Duration | 4–72 hours | 30 min–7 days | 15–180 min |
| Autonomic features | Rare | No | Yes (ipsilateral) |
| Nausea/photophobia | Yes | Mild/absent | No |
| Activity effect | Worsened | Not worsened | Restlessness/pacing |
A complete headache history, combined with a targeted neurological examination, usually allows for accurate diagnosis without imaging in patients with no red flags.
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