Headache history taking

geekymedics.com /headache-history-taking/

2/20/2016

Headache is a common presenting complaint and certainly something youll encounter many times over your
career. The vast majority of headaches are not life threatening, with tension headache and migraine being the most
common diagnoses. Headache is however also associated with a number of serious conditions and therefore it is
essential you are able to take a comprehensive headache history and identify red flags that indicate the need for
further investigation. Check out the headache history taking OSCE mark scheme here.

Opening the consultation

Introduce yourself name / role

Confirm patient details name / DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

Presenting complaint
Its important to use open questioning to elicit the patients presenting complaint

So whats brought you in today? or Tell me about your headache

Allow the patient time to answer, trying not to interrupt or direct the conversation.

Facilitate the patient to expand on their presenting complaint if required.

Ok, so tell me more about that Can you explain what that pain was like?

History of presenting complaint

The aim now is to encourage the patient to give further details about their complaint to allow you to narrow the
differential diagnosis. One useful way to gain further details about a headache is to use the SOCRATES system of
questions as shown below.

Site unilateral (e.g. migraine) / frontal bilateral (e.g. tension headache)

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Onset:

Was the onset acute or gradual? (sudden onset thunderclap headache is suggestive
of subarachnoid haemorrhage)

Character aching / throbbing / pounding / pulsating / pressure / pins and needles / stabbing

Radiation neck (meningitis) / face (e.g. trigeminal neuralgia) / eye (e.g. acute closed angle glaucoma)

Associated symptoms:

Nausea / vomiting may suggest raised intracranial pressure (ICP)

Visual disturbance aura related / intracranial lesion / bleeding / stroke
Photophobia raised ICP / meningitis
Neck stiffness meningitis (may be related to infection or subarachnoid haemorrhage)
Fever suggestive of an infective process (e.g. bacterial meningitis / abscess)
Rash non-blanching purpuric rash may indicate meningococcal sepsis
Weight loss suggestive of malignancy consider cerebral metastases
Sleep disturbance headaches causing sleep disturbance are concerning (raised ICP)
Temporal region tenderness consider temporal arteritis
Neurological deficits weakness / sensory disturbance / impaired coordination / cognitive symptoms /
altered level of consciousness consider space occupying lesions / intracranial bleeding / stroke

Timing:

Duration of headache?
Is it episodic?
Any clear pattern?
Diurnal variation?
Chronic headaches in a month of 30 days, for how many of those days would the patient have a
headache?

Exacerbating / relieving factors:

Exacerbating factors are there any obvious triggers for the symptom? (e.g. caffeine / codeine / stress /
postural change)
Relieving factors does anything appear to improve the symptoms (e.g. improvement upon lying flat
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 suggestive of reduced ICP).

Severity:

Ask the patient to rate the pain on a scale of 1-10

Is the pain getting worse?
How is it impacting their daily life?

Red flags

Red flags within a headache history are many and varied, so familiarise yourself with common patterns.

A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid
haemorrhage).
Fever with a worsening headache, meningeal irritation and change in mental status (viral / bacterial
meningitis).
New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial haemorrhage /
ischaemic stroke / space occupying lesion).
Decreased level of consciousness.
Head trauma (more significant if within the last three months).
Headache which is posture dependent (e.g. worse on lying down and coughing with raised ICP).
Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication
(temporal arteritis).
Headache associated with severe eye pain / blurred vision / nausea and vomiting / red eye (acute angle
closure glaucoma).

Ideas, Concerns and Expectations

Ideas what are the patients thoughts regarding their symptoms?

Concerns explore any worries the patient may have regarding their symptoms

Expectations gain an understanding of what the patient is hoping to achieve from the consultation

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

Once you have summarised, ask the patient if theres anything else that youve overlooked.

Continue to periodically summarise as you move through the rest of the history.
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Signposting

Signposting involves explaining to the patient:

What you have covered Ok, so weve talked about your symptoms and your concerns regarding them
What you plan to cover next Now Id like to discuss your past medical history and your medications

Past medical history

Previous episodes of headache / migraine?

Previous intracranial bleeds? (e.g. subarachnoid haemorrhage)

Head trauma in last three months?

History of malignancy?

Other medical conditions?

Previous surgery? e.g. CSF shunting (blocked / infected shunts present with headache)

Drug history
Regular prescribed medication?

Anticoagulants or antiplatelets? e.g. Warfarin / Aspirin

Analgesia for headache?

Clarify dosages and frequencies

In a month with 30 days, on how many days would they use painkillers?
Do the painkillers fully relieve the pain?

Over the counter drugs or herbal remedies?

ALLERGIES document these clearly

Family history
Neurological diagnoses in first degree relatives? e.g. migraine

Social history
Smoking How many cigarettes a day? How long have they smoked for?

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Alcohol How many units a week? be specific about type / volume / strength of alcohol

Recreational drug use headache may be withdrawal related

Living situation:

House / Flat stairs / adaptations

Who lives with the patient? important when considering discharging home from hospital
Any carer input? what level of care do they receive?

Activities of daily living:

Is the patient independent / able to fully care for themselves?

Can they manage self hygiene / housework / food shopping?
Is the headache interfering significantly with their daily life?

Occupation clarify their role and daily responsibilities

Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

Cardiovascular Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema

Respiratory Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit

Urinary Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

Musculoskeletal Bone and joint pain / Muscular pain

Dermatology Rashes / Skin breaks / Ulcers / Lesions

Closing the consultation

Thank patient

Summarise history

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