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History taking Headache

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Opening the consult Greet the patient ask the patient to sit collect token

History of presenting complaint

SOCRATES

The SOCRATES acronym (explained below) is a useful tool that you can use to further explore the characteristics of the patient’s headache.

Site

Ask about the location of the headache:

  • “Where is the headache?”
  • “Can you point to where you experience the headache?”

Migraines typically present as a unilateral headache whereas bilateral headache is most commonly associated with a tension headache.

Onset

Clarify how and when the headache developed:

  • “Did the headache come on suddenly or gradually?”
  • “When did the headache first start?”
  • “How long have you been experiencing the headache?”

Headaches that have a very sudden onset, reaching their maximum intensity within seconds are typically associated with subarachnoid haemorrhage (often described as ‘thunderclap’ in nature).

Character

Ask about the specific characteristics of the headache:

  • “How would you describe the headache?”
  • “Is the headache constant or does it come and go?”

Common descriptors of headaches may include: ‘aching’, ‘throbbing’, ‘pounding’, ‘pulsating’, ‘pressure’, ‘pins and needles’ and ‘stabbing’.

Radiation

Ask if the headache moves anywhere else:

  • “Does the headache spread elsewhere?”

The radiation of a headache to another anatomical location may help to narrow the differential diagnosis:

  • Radiation to the neck is associated with meningitis.
  • Radiation to the face may suggest a diagnosis of trigeminal neuralgia.
  • Radiation to the eye occurs in acute closed-angle glaucoma.

Associated symptoms

Ask if there are other symptoms which are associated with the headache:

  • “Are there any other symptoms that seem associated with the headache?”

See the key symptoms section below for examples.

Time course

Clarify how the headache has changed over time:

  • “How has the headache changed over time?”
  • “Is the headache worse at a particular time of day?”
  • “In a 30 day period, how many of those days would you experience the headache on average?”

Headaches that are worse in the mornings are suggestive of raised intracranial pressure (e.g. space-occupying lesion).

Exacerbating or relieving factors

Ask if anything makes the headaches worse or better:

  • “Does anything seem to trigger or make the headaches worse?”
  • “Does anything make the headaches better?”

Triggers for headaches may include caffeine, excessive codeine use, stress, coughing (suggestive of raised ICP), lying flat (suggestive of raised ICP) and standing up (suggestive of low ICP).

Relieving factors for headaches may include hydration, standing up (suggestive of raised ICP) and lying down (suggestive of low ICP).

Severity

Assess the severity of the headaches by asking the patient to grade it on a scale of 0-10:

  • “On a scale of 0-10, how severe is the headache, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Ask the patient how the headaches are affecting their daily life. Regular migraines may make it difficult for the patient to function.

Key symptoms to ask about

Key symptoms to ask about when taking a headache history include:

  • Nausea and vomiting: may indicate raised intracranial pressure (e.g. space-occupying lesion).
  • Visual disturbance: may be migraine aura related or secondary to local neural compression by a space-occupying lesion or haemorrhage.
  • Photophobia: most commonly associated with migraine, but also a typical finding in meningitis which may be chemical (e.g. subarachnoid haemorrhage) or infective (e.g. bacterial meningitis).
  • Neck stiffness: commonly associated with meningitis but may also be due to musculoskeletal issues of the neck which can also cause headaches (cervicogenic headache).
  • 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).
  • Rash: a non-blanching purpuric rash may indicate meningococcal sepsis.
  • Weight loss: may indicate underlying malignancy (e.g. primary intracranial tumour or brain metastases).
  • Sleep disturbance: headaches which disturb sleep are concerning for serious underlying pathology (e.g. raised intracranial pressure).
  • Temporal region tenderness: associated with temporal arteritis. Patients may report tenderness when brushing their hair.
  • Neurological deficits: these may include motor or sensory deficits, cognitive symptoms or a reduced level of consciousness. Different patterns of these symptoms may be present in a wide range of pathology (e.g. migraine, space-occupying lesions, intracranial infection and intracranial haemorrhage).
Red flag features

It is important that you recognise red flag features in a headache history which warrant urgent further investigation.

Examples of some red flag presentations include:

  • A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid haemorrhage).
  • Worsening headache associated with fever, meningeal irritation (i.e. neck stiffness) and altered mental status (suggestive of bacterial, viral or fungal meningitis).
  • New onset focal neurological deficit, personality change or cognitive dysfunction (e.g. intracranial haemorrhage, space-occupying lesion, encephalitis, meningitis).
  • Decreased level of consciousness (e.g. raised intracranial pressure).
  • Recent head trauma within the last 3 months (e.g. subdural haemorrhage).
  • Headache which is posture dependent (e.g. a headache worse on lying down and when coughing is suggestive of raised ICP).
  • Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication (e.g. temporal arteritis).
  • Headache associated with severe eye pain, reduced vision, nausea and vomiting (e.g. acute angle-closure glaucoma).

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 fluid throughout the consultation in response to patient cues. 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:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

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 different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

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: fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy)
  • Respiratory: dyspnoea, cough (e.g. lung cancer)
  • Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain (e.g. gastrointestinal malignancy)
  • Genitourinary: oliguria (e.g. dehydration)
  • Musculoskeletal: neck pain (e.g. cervicogenic headache)
  • Dermatological: rashes (e.g. meningococcal sepsis)

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

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 (e.g. neurosurgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

Allergies

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 anaphylaxis).

Examples of relevant medical conditions

Medical history relevant to headaches includes:

  • Recent head trauma (last three months)
  • Migraine
  • Benign intracranial hypertension
  • Cerebrospinal fluid shunt devices (blocked or overdraining shunts present with headache)
  • Subarachnoid haemorrhage
  • Acute angle-closure glaucoma
  • Cancer (any site due to potential of brain metastases)
  • Hypertension (risk of malignant hypertension and haemorrhagic stroke)
  • Infectious disease (risk of cerebral abscess)
  • Thrombophilia (increased risk of venous sinus thrombosis)
  • Bleeding disorders (increased risk of intracranial bleeding)
  • Polymyalgia rheumatica (increased risk of temporal arteritis)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Specifically ask about blood-thinning medications such as aspirin, warfarin and NOACs (e.g. apixaban).

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Ask the patient if they are using any medication to treat their headaches and gather details of how frequently they are using these medications:

  • “Are you currently taking anything to treat the headaches?”
  • “How many days in a month are you using the medications?”
Medication-overuse headache

Medication overuse headache is counterintuitively associated with medications used for the treatment of headache. Overuse of these medications is defined as use on more than 15 days of a month. Medications which are associated with medication-overuse headaches include:

  • Opiates (e.g. codeine and co-codamol)
  • Triptans
  • NSAIDs (e.g. ibuprofen, aspirin)
  • Paracetamol

Family history

Ask the patient if there is any family history of headaches, cancer, bleeds on the brain, clotting disorders or bleeding disorders:

  • “Do any of your parents or siblings have problems with headaches such as migraines?” 
  • “Have your parents or siblings ever been told they have a bleeding or clotting disorder?”
  • “Have your parents or siblings ever suffered from bleeds on the brain or cancer?”

Clarify at what age these diseases developed (disease developing at a younger age is more likely to be associated with genetic factors):

  • “At what age did your father develop the subarachnoid haemorrhage?”
  • “When was your mother first diagnosed with lung cancer”

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 really sorry to hear that, do you mind me asking how old your dad was when he died?”
  • “Do you remember what medical condition was felt to have caused his death?”

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)
  • whether there is a gas fire or boiler and if they have a carbon monoxide detector (carbon monoxide poisoning can present with headache and drowsiness)
  • 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

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

Smoking is an important risk factor for both malignancy and thrombotic disease

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.

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.