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11/13/24, 8\:10 PM Guide | Headache history

Headache history

Table of contents

Background

Headache is one of the most common presenting complaints to general practice and the emergency department, with
headache disorders a
than 15 days of the month.
Most headaches are not life-threatening, with the majority being tension-type headaches or migraines. 1
many causes of headache with serious underlying pathology that can often be identi
comprehensive headache history.
However, there are

Causes of headaches

The causes of headache can be split into primary, in which there is no association to an underlying condition, or secondary,
due to underlying local or systemic pathology. 2-3
It is important to remember that patients may present with more than one
headache pathology.
Primary
Primary causes of headache include\:
Migraine\: moderate to severe intensity attacks, which are often unilateral and throbbing or pulsating in nature. They are often
associated with photophobia, phonophobia, nausea and vomiting. They can occur with or without an aura, which is a
transient, focal, neurological symptom that precedes or accompanies the headache.
4
Tension-type headache\: mild to moderate intensity attacks that are typically bilateral and pressing or tightening. There can
be photophobia or phonophobia, but not both; there would not be any other associated symptoms.
Trigeminal autonomic cephalalgias\: these include cluster headaches which cause severe episodes of unilateral pain
associated with lacrimation, rhinorrhoea and facial sweating.
5
Secondary
Secondary causes of headache include\:
Traumatic\: musculoskeletal (including neck), concussion, head injury
Vascular\: intracranial haemorrhage, giant cell arteritis, stroke
Infective\: meningitis, encephalitis, rhinosinusitis
Cranial neuropathies\: trigeminal neuralgia, post-herpetic neuralgia, optic neuritis
Other\: medication overuse, substance misuse, drug side eacute angle-closure glaucoma,
hypertension
For further information, see the Geeky Medics guide to headaches.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
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General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

SOCRATES

The SOCRATES acronym is a useful tool for exploring a patient's symptoms in more detail, particularly with a presenting
complaint of pain.
Site
Ask about the location of the headache\:
" W h e r e i s t h e h e a d a c h e ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e h e a d a c h e ?"
Di
type headaches are mostly frontal and bilateral, cluster headaches are often behind one eye, and subarachnoid
haemorrhages are occipital.
Onset
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Clarify how and when the headache developed\:
" D i d t h e h e a d a c h e c o m e o n s u d d e n l y o r gr a d u a l l y ?"
" W h e n d i d t h e h e a d a c h e
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e h e a d a c h e ?"
It is important to consider whether anything preceded the headache as a trigger. Recent head trauma should raise concerns
for an intracranial haemorrhage, and a headache triggered by a Valsalva manoeuvre (e.g. coughing or sneezing) should raise
suspicion for a space-occupying lesion. Benign triggers for headaches may include ca
stress.
A sudden onset of headache, reaching maximum intensity within seconds ('thunderclap'), would be concerning for a
subarachnoid haemorrhage or another vascular cause, such as dissection or thrombosis.
The age of onset is important, as a new onset of headache in an over-50-year-old may indicate temporal arteritis or a space-
occupying lesion.
6
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e h e a d a c h e ?"
" I s t h e h e a d a c h e c o n s t a n t , o r d o e s i t c o m e a n d go ?"
Common descriptors of headaches may include\:
'aching'
,
'stabbing'
.
'throbbing'
,
'pounding',
'pulsating'
,
'pressure'
,
'pins and needles' and
Radiation
Ask if the headache moves anywhere else\:
" D o e s t h e h e a d a c h e s p r e a d e l s e w h e r e ?"
The radiation of a headache to another area may give clues to the di
Radiation to the back of the neck may be associated with meningitis
Radiation to the face can suggest trigeminal neuralgia
Radiation along the lateral scalp occurs in giant cell arteritis
Asking the patient to indicate the spread of their pain may even highlight that it is radiating from another area, such as the neck
or teeth, allowing you to adjust your history taking approach to focus on a di
Associated symptoms
Ask if there are other symptoms which are associated with the headache\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e h e a d a c h e ?"
Except for auras in migraine, most primary headaches occur without associated symptoms. Asking about speci
associated with a headache is very important as they are often features that could suggest a serious underlying cause.
6-7
Time course
Clarify how the headache has changed over time\:
" H o w h a s t h e h e a d a c h e c h a n g e d o v e r t i m e ?"
" I s t h e h e a d a c h e w o r s e a t a p a r t i c u l a r t i m e o f d a y ?"
" I n a 3 0 d a y p e r i o d , h o w m a n y o f t h o s e d a y s w o u l d y o u e x p e r i e n c e t h e h e a d a c h e o n a v e r a ge ?"
Headaches that are progressive, persistent or changing over time are much more concerning for a serious underlying cause.
The presence of a headache on waking is in keeping with raised intracranial pressure.
9
Exacerbating or relieving factors
Ask if anything makes the headaches worse or better\:
" D o e s a n y t h i n g m a k e t h e h e a d a c h e w o r s e ?"
" D o e s a n y t h i n g m a k e t h e h e a d a c h e b e t t e r ?"
These factors can give particular clues for headaches due to raised intracranial pressure (space-occupying lesion, idiopathic
intracranial hypertension) or intracranial hypotension (CSF leak post lumbar puncture)\:
Raised intracranial pressure\: suggested by worsening with lying
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Intracranial hypotension\: suggested by worsening with standing and improving on lying
8
Severity
Assess the severity of the headaches by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e h e a d a c h e , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
Ask the patient how the headaches are a
function and may lead to time o
Key symptoms to ask about
Most patients presenting with a headache will not have a serious cause; however, it is important to explore red
symptoms and features in the history that may warrant emergency admission or urgent specialist review.
6, 8
Vomiting\: may indicate raised intracranial pressure due to a space-occupying lesion
Visual disturbance\: can be seen in migraines but may also be a feature of space-occupying lesions
Neck sti
associated with meningitis and subarachnoid haemorrhage
Fever\: indicative of an infective process which may be viral (e.g. HSV encephalitis), bacterial (e.g. cerebral abscess) or
fungal (e.g. fungal meningitis)
Dizziness\: if sudden, may be caused by a stroke
Rash\: a non-blanching purpuric rash may indicate meningococcal sepsis
Weight loss\: may indicate underlying malignancy, either primary neurological or another site that has metastasised
Seizure\: a seizure with a headache is highly concerning for an underlying infection or space-occupying lesion
Neurological de
level of consciousness. Di
migraine, space-occupying lesions, intracranial infection and intracranial haemorrhages.
Parts of the history that should consider red
Onset\: sudden onset and severe (subarachnoid haemorrhage), new onset over 50 years old (space-occupying lesion,
temporal arteritis), evolution of headache (space-occupying lesion, subdural haematoma)
Triggers\: head trauma (intracranial haemorrhage), Valsalva manoeuvre (space occupying lesion), worse on standing
(CSF leak), worse on lying (space occupying lesion)
Comorbidities\: immunocompromise (infection), current or past malignancy (cerebral metastasis)
Other\: contacts with similar symptoms (carbon monoxide poisoning)

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
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" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
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

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever, unintentional weight loss
Respiratory\: dyspnoea, chronic cough
Cardiovascular\: palpitations, chest pain
Gastrointestinal\: nausea, vomiting, dysphagia, abdominal pain, change in bowel habit
Genitourinary\: oliguria
Musculoskeletal\: neck pain
Dermatological\: rashes
Psychological\: stress, anxiety, depression, substance misuse

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures\:
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" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Examples of relevant medical conditions
Patients with a headache may present with a prior history of a primary headache disorder. It is still important to take a
thorough history to ensure the diagnosis is correct. Other relevant medical conditions in the context of headache include\:
For infective causes\:
Risk factors for immunosuppression (e.g. HIV or diabetes mellitus)
Procedures or conditions that increase the risk of infection (e.g. recent surgery or cerebrospinal
For vascular causes\:
Conditions that increase the risk of thrombosis (e.g. hypertension, hyperlipidemia or thrombophilia)
Conditions that increase the risk of haemorrhage (e.g. clotting disorders or aneurysms)
For traumatic/degenerative causes\:
Head trauma within the last 3 months
Pain from the neck may radiate and cause pain experienced in the head (e.g. osteoarthritis of the cervical spine)
For neoplastic causes\:
Any history of current or past malignancy, as brain metastases are a serious cause of headaches
For in
Temporal arteritis is associated with polymyalgia rheumatica
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
" A r e y o u c u r r e n t l y t a k i n g a n y t h i n g t o t r e a t t h e h e a d a c h e s ?"
" H o w m a n y d a y s i n a m o n t h a r e y o u u s i n g t h e m e d i c a t i o n s ?"
If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form
and route. Speci
a patient who has migraines with aura).
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
" D i d y o u n o t i c e t h a t y o u r h e a d a c h e s t a r t e d , o r w o r s e n e d , a f t e r s t a r t i n g a n y m e d i c a t i o n ?"
Medication-overuse headache
A medication overuse headache develops as a consequence of regular (>3 months) overuse of one or more drugs used
for acute treatment of headaches. It usually, but not always, resolves after the overused medication is stopped.
Associated medications include\:
2
Opiates (taken >10 days per month)
Triptans (taken >10 days per month)
NSAIDs (taken >15 days per month)
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Paracetamol (taken >15 days per month)

Family history

Ask the patient if there is any family history of headaches, cancer, clotting disorders or bleeding disorders\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e p r o b l e m s w i t h h e a d a c h e s s u c h a s m i gr a i n e s ?"
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?"
Clarify at what age these diseases developed (disease developing at a younger age is more likely to be associated with
genetic factors).
If one of the patient's close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
" I' m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?"

Social history

Explore the patient's social history to both understand their social context and identify potential risk factors for headaches.
General social context
Explore the patient's general social context including\:
The type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
Who else the patient lives with and their personal support network
What tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
If they have any carer input (e.g. twice daily carer visits)
Smoking
and thrombotic disease.
Record the patient's smoking history, including the type and amount of tobacco used. Smoking is a risk factor for malignancy
Calculate the number of 'pack-years' the patient has smoked for to determine their risk pro
Pack-years = [number of years smoked] x [average number of packs smoked per day]
One pack is equal to 20 cigarettes
For further information, read the Geeky Medics guide to smoking cessation.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol can cause headaches, particularly when used excessively. Patients may also experience alcohol withdrawal
headaches.
For further information, read the Geeky Medics guide to alcohol history taking.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Headaches can be associated with the use of cocaine, amphetamines and cannabis.
Occupation
Ask about the patient's current occupation\:
Assess the impact of their symptoms on their ability to work
Ask about their responsibilities and identify potential exposure to agents such as carbon monoxide, which can cause
headaches
Identifying if the patient drives as some causes of headache may require the DVLA to be informed
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Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. Andreou AP, Brennan KC, Burstein R, et al. T h e r o l e o f t h e b r a i n s t e m i n h e a d a c h e d i s o r d e r s \: I n s i gh t s f r o m m i gr a i n e a n d c l u s t e r
h e a d a c h e . The Journal of Headache and Pain, 23(44). 2022. Available from\: [LINK]
2. Headache Classi
H e a d a c h e D i s o r d e r s , 3 r d e d i t i o n . Cephalalgia, 38(1), 1-211. Available from\: [LINK]
3. Patel S, Young WB. H e a d a c h e . StatPearls. 2019. Available from\: [LINK]
4. NICE Clinical Knowledge Summaries. M i g r a i n e . 2023. Available from\: [LINK]
5. NICE Clinical Knowledge Summaries. C l u s t e r h e a d a c h e . 2023. Available from\: [LINK]
6. NICE Clinical Knowledge Summaries. H e a d a c h e a s s e s s m e n t . 2023. Available from\: [LINK]
7. Digre KB. N e u r o-o p h t h a l m o l o g y i n m i g r a i n e . Current Pain and Headache Reports, 19(10), 43. 2015. Available from\: [LINK]
8. Ashina M, Katsarava Z, Do TP. E p i d e m i o l o g y o f h e a d a c h e d i s o r d e r s . Journal of Clinical Neuroscience, 57, 34-40. 2018. Available
from\: [LINK]
9. Parveen K, Clarke M. K u m a r a n d C l a r k e C l i n i c a l M e d i c i n e (9th ed.). Elsevier. 2017.

Reviewer

Dr Ryan Jennison
General Practioner
Source\: geekymedics.com
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