Headache is a common presenting complaint and certainly something you’ll 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.
Opening the consultation
Introduce yourself – name/role
Confirm patient details – name/DOB
Explain the need to take a history
Ensure the patient is comfortable
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s 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)
- 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)
- 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
- 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 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 suggestive of reduced ICP).
- 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 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/vomiting/red eye (acute angle closure glaucoma)
Ideas, Concerns and Expectations
Ideas – what are the patient’s 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
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 there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
- What you plan to cover next – “Now I’d 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)
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
Neurological diagnoses in first degree relatives? – e.g. migraine
Smoking – How many cigarettes a day? How long have they smoked for?
Alcohol – How many units a week? – be specific about type / volume / strength of alcohol
Recreational drug use – headache may be withdrawal related
- House / Flat – stairs/adaptations
- Who lives with the patient? – important when considering discharging home from the 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 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. neck stiffness in meningitis).
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