Headache history taking
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Here is a comprehensive guide to headache history taking, synthesized from multiple authoritative sources:
Headache History Taking
1. Five Core Elements of the History
According to Goldman-Cecil Medicine, five elements are key when evaluating headaches:
| Element | What to Assess |
|---|---|
| Family history | Genetic predisposition (especially migraine) |
| Life history of headache | Is it new-onset or chronic/evolving over years? |
| Attack history | Clinical features of each headache episode |
| Medical & psychiatric history | Comorbidities that may cause or worsen headache (depression, anxiety, obesity) |
| Medication & drug history | Medications, analgesic overuse, drugs of abuse, steroids |
2. Detailed Attack History (SOCRATES)
Onset
- When did the headaches first begin?
- How did it start — sudden ("thunderclap": onset to maximum within 5 min) or gradual?
- Any precipitant: trauma, exertion, sexual activity, cough/Valsalva?
Site & Radiation
- Where is the pain? Unilateral, bilateral, frontal, occipital, periorbital?
- Does it radiate to the neck, jaw, or teeth?
- Focal occipital pain is concerning for secondary headaches
Character
- Throbbing/pulsating → migraine
- Band-like, pressure/tight → tension-type
- Severe stabbing or burning around eye/face → cluster
Severity
- Score on 0–10 scale
- Does it interfere with activity (worsens vs. improves with activity)?
Timing & Pattern
- Frequency (episodic vs. daily persistent) and duration (seconds → cluster/SUNCT; hours–days → migraine/tension)
- Time of day — worse on waking? (raised ICP)
- Progressive worsening vs. stable pattern
Associated Symptoms
- Nausea, vomiting (especially vomiting preceding headache — red flag)
- Photophobia, phonophobia
- Aura or prodrome (focal visual, sensory, or motor symptoms before the headache)
- Autonomic features: ptosis, miosis, lacrimation, rhinorrhea, conjunctival injection, Horner syndrome, facial edema
- Constitutional: fever, weight loss, visual changes
- Neurologic: weakness, tingling, diplopia, visual field defects, altered consciousness
Relieving & Exacerbating Factors
- What makes it better or worse?
- Position: worse supine or with Valsalva (cough, straining, bending, lifting)?
- Activity: migraine worsens with movement; tension-type often improves with activity
- Triggers: stress, sleep disruption, caffeine, menstrual cycle, certain foods
3. Red Flags ("SNOOP4" features)
These suggest a potentially serious secondary cause requiring urgent investigation:
| Red Flag | Concern |
|---|---|
| Sudden-onset / thunderclap | Subarachnoid hemorrhage (SAH) |
| First / "worst headache ever" | SAH, meningitis |
| Subacute worsening over days–weeks | Raised ICP (tumour, haematoma) |
| Positional worsening (supine) or Valsalva | Space-occupying lesion, IIH |
| Pain that awakens from sleep | Raised ICP |
| Onset after age 55 | GCA, malignancy |
| Fever / systemic signs | Meningitis, encephalitis, systemic infection |
| New neurologic signs | Stroke, haematoma, tumour |
| Optic disc oedema / visual changes atypical for migraine | IIH, GCA |
| Nuchal rigidity / altered consciousness | Meningitis, haemorrhage |
| Vomiting preceding headache | Raised ICP |
| Immunocompromised / anticoagulated | Opportunistic infection, haematoma |
| Progressively worsening over time | Tumour, hydrocephalus |
4. Relevant Past & Social History
- Prior headache diagnoses and treatments
- Previous neuroimaging
- Medications: analgesic frequency (≥10 days/month = medication-overuse headache risk), OCP, nitrates, steroids
- Psychiatric history: depression and anxiety are common comorbidities and can both coexist with and worsen headache
- Sleep history (sleep apnoea → morning headaches)
- Functional impact: school/work absences, disability
5. Differential Diagnosis by Pattern
| Headache Type | Key Features | Duration | Associated Symptoms |
|---|---|---|---|
| Migraine | Unilateral, throbbing, moderate–severe, worsens with activity | Hours–days | Photophobia, phonophobia, N&V, aura |
| Tension-type | Bilateral, band-like, mild–moderate, improves with activity | Hours–days | No N&V; minimal light/sound sensitivity |
| Cluster | Severe unilateral facial/orbital, circadian periodicity | 15 min–3 hr | Ipsilateral ptosis, lacrimation, rhinorrhoea, conjunctival injection |
| Paroxysmal hemicrania | Unilateral facial | Minutes | Same autonomic features; responds to indomethacin |
| Hemicrania continua | Continuous unilateral, with stabs | Continuous | Autonomic features; responds to indomethacin |
| SAH | Thunderclap, "worst ever" | Sudden/persistent | Meningism, ± LOC |
| IIH | Daily, worsens lying/bending | Progressive | Visual obscurations, papilloedema |
| Meningitis | Acute severe + stiff neck + fever | Evolving | Photophobia, N&V |
6. Initial Investigations to Consider
- CT brain: first-line for suspected haemorrhage, acute severe headache
- MRI brain: for subacute/chronic worrying features
- LP: mandatory if meningitis or SAH suspected (even after normal CT)
- Fundoscopy: to check for papilloedema
- BP measurement: hypertensive headache
- ESR/CRP/temporal artery biopsy: if GCA suspected (age >50, jaw claudication, temporal tenderness)
Sources: Goldman-Cecil Medicine, Ch. 367 | Harrison's Principles of Internal Medicine 22e, Ch. 17 | The Harriet Lane Handbook 23e, Ch. 20
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