Headache history taking
Reading File
Finding Sources
Finding Sources
Reading File
Finding Sources
Reading File
Reading File
Reading File
I now have comprehensive content. The file read shows Box 20.2 and all the major headache history-taking sections. Let me compile the full answer.
Headache History Taking
The gold standard for headache diagnosis is a careful clinical interview. In the vast majority of patients, the neurological and general examinations are normal — the diagnosis rests entirely on the history. Time spent with the patient interviewing is therefore more valuable than ordering tests.
1. Opening the Interview
Begin by asking the patient to describe their symptoms in their own words, or simply ask how you can help. Without interruption, most patients will finish in under 2 minutes. Then follow with directed but open-ended questions.
2. Core History-Taking Framework
A. How Many Types of Headache?
Establish this first. Many patients have more than one type (e.g., migraine + tension-type). Each type must be delineated separately. A change in an established headache pattern may signal a new underlying condition.
B. Onset
| Feature | Implication |
|---|---|
| Stable disorder for years | Almost always benign |
| Recent onset (within 1–12 months) | Greater risk of secondary cause |
| Onset after age 50 | Suspect giant cell arteritis, neoplasm |
| Rapid-onset "thunderclap" (seconds to minutes) | Subarachnoid hemorrhage, RCVS, venous thrombosis, dissection, pituitary apoplexy — must be excluded |
| Progressive worsening | Raises suspicion of intracranial lesion |
| "Worst headache of life" | Subarachnoid hemorrhage until proven otherwise |
C. Location / Distribution
- Unilateral: Migraine, cluster, trigeminal neuralgia, hemicrania continua
- Bilateral / band-like: Tension-type
- Strictly unilateral (side-locked): Yellow flag — may indicate structural lesion
- Periorbital / retro-orbital: Cluster, acute angle-closure glaucoma
- Occipital / nuchal: Subarachnoid hemorrhage, posterior fossa pathology
- Facial: Trigeminal neuralgia, sinusitis, dental causes
D. Character / Quality
- Throbbing / pulsating: Migraine
- Pressure / tightening / band-like: Tension-type
- Excruciating, stabbing: Cluster, trigeminal neuralgia
- Sudden explosive: Thunderclap — vascular emergency
E. Severity
Use a 0–10 scale. Severe pain ≥7 warrants closer attention. The severity alone does not distinguish benign from dangerous headaches — context is critical.
F. Duration and Frequency
| Duration | Typical Diagnosis |
|---|---|
| 4–72 hours | Migraine |
| 30 minutes – 7 days | Tension-type |
| 15–180 minutes | Cluster headache |
| Seconds | Primary stabbing, trigeminal neuralgia |
| Continuous / daily | Hemicrania continua, medication overuse |
Ask about frequency and whether it is increasing.
G. Timing and Pattern
- Time of day: Cluster headaches are nocturnal and wake patients from sleep
- Sleep-related headache: Wakes patient from sleep = yellow/red flag (hypnic headache, cluster, raised ICP)
- Immediate onset on awakening: Raises concern for raised intracranial pressure
- Postural headache: Worse on standing → low CSF pressure; worse on lying down → high ICP
H. Associated Symptoms
Neurological:
- Aura (visual, sensory, motor, speech) → migraine with aura
- Focal neurological deficits → secondary cause, stroke
- Altered consciousness, seizures → serious secondary pathology
- Visual loss, jaw claudication → giant cell arteritis
Autonomic (cranial):
- Lacrimation, rhinorrhoea, conjunctival injection, ptosis, miosis, eyelid oedema → trigeminal autonomic cephalalgias (cluster, SUNA, paroxysmal hemicrania)
Systemic:
- Fever, neck stiffness, photophobia, phonophobia → meningitis (note: photophobia and phonophobia also occur in migraine)
- Nausea and vomiting
- Vomiting preceding the headache → raised ICP
I. Aggravating and Relieving Factors
| Factor | Implication |
|---|---|
| Worsened by movement / Valsalva (coughing, bending, lifting) | Raised ICP, primary cough headache |
| Relieved by lying still in a dark room | Migraine |
| Worse with lying down, better standing | Raised ICP |
| Worse standing, better lying | Low CSF pressure (intracranial hypotension) |
| Triggered by cold, exercise, sexual activity | Primary headache disorders of same name |
| Triggered by alcohol | Cluster headache |
J. Prodrome and Postdrome
- Prodrome (hours before): mood change, food cravings, yawning, fatigue → migraine
- Aura (20–60 min before / during): visual zigzag (fortification spectra), scotoma, sensory, motor → migraine with aura
- Postdrome: fatigue, cognitive fog after resolution → migraine
K. Precipitating / Trigger Factors
- Stress, sleep deprivation, skipped meals, hormonal changes (menstruation), certain foods (wine, cheese, chocolate), bright light, strong smells, weather changes → migraine triggers
- Recent head/neck trauma
- New medications, substances (nitrates, oral contraceptives, overuse of analgesics)
- Recent illness, travel, immunosuppression
L. Medication History
- Current and past headache medications
- Analgesic/triptan frequency: ≥10–15 days/month use raises concern for medication overuse headache
- Vasodilators (nitrates), phosphodiesterase inhibitors, oral contraceptives can trigger or worsen headaches
- Recent changes in antihypertensives or anticoagulants
M. Past Medical and Family History
- Previous similar episodes
- Family history of migraine (strong genetic component)
- History of hypertension, coagulopathy, malignancy, HIV/immunosuppression
- Psychiatric history: anxiety and depression are common migraine comorbidities
N. Social History
- Caffeine intake and withdrawal patterns
- Alcohol use
- Recent travel (travel to endemic areas → infectious cause)
- Occupation (screen exposure, stress, carbon monoxide risk)
3. Red and Yellow Flags (SNOOP4 / Warning Flags)
These features increase the likelihood of a serious secondary cause and warrant urgent investigation:
🔴 Red Flags
| Flag | Mnemonic |
|---|---|
| Systemic symptoms (fever, weight loss, night sweats) | S |
| Systemic illness (HIV, malignancy) | S |
| Neurological symptoms / abnormal examination | N |
| Onset sudden / thunderclap | O |
| Onset after age 50 | O |
| Progressive worsening | P |
| Papilledema | P |
| Precipitated by Valsalva (cough, exertion, sex) | P |
| Postural change in pain | P |
| "Worst headache ever" | — |
| Prior headache history absent (new pattern) | — |
| Pregnancy / postpartum | — |
🟡 Yellow Flags (Worrisome but Less Urgent)
- Wakes patient from sleep at night
- New-onset side-locked headache
- Postural headaches
4. Psychological Assessment
Screen for depression and anxiety — both are common comorbidities with headache, and some antidepressants are also effective headache preventives. Psychological factors should be identified as comorbidities, not assumed to be the cause of headache.
5. Key Diagnostic Implications Summary
| Headache Type | Key History Features |
|---|---|
| Migraine | Unilateral, throbbing, 4–72h, nausea/vomiting, photophobia, phonophobia, aura, family history, worsened by activity |
| Tension-type | Bilateral, pressing/tightening, mild-moderate, not worsened by activity |
| Cluster | Strictly unilateral, periorbital, excruciating, 15–180 min, autonomic features, nocturnal, male predominance |
| SAH | Thunderclap, "worst ever," occipital, neck stiffness, vomiting precedes pain |
| Meningitis | Fever, neck stiffness, photophobia, progressive headache |
| Raised ICP | Worse on bending/Valsalva, wakes from sleep, papilledema, vomiting without nausea |
| Giant cell arteritis | Age >50, temporal tenderness, jaw claudication, visual disturbance, raised ESR |
| Medication overuse | Daily/near-daily headache, frequent analgesic/triptan use |
Sources: Bradley and Daroff's Neurology in Clinical Practice, p. 339–341 | Harrison's Principles of Internal Medicine 22E, p. 340
This is a shared conversation. Sign in to Orris to start your own chat.