Headache
Neurology
Introduction
Author: Naqiyya Hassanali
Taking a thorough headache history is crucial to accurately diagnose and manage different headache types. Key principles include assessing the onset, duration, and pattern of headaches, as well as their location, quality, and intensity. Identifying triggers, aggravating or relieving factors, and associated symptoms (such as nausea, visual disturbances, or neurological signs) helps differentiate between primary and secondary headaches. A detailed medical and family history provides insight into potential genetic or underlying causes. Additionally, understanding the impact on daily life and response to previous treatments guides management decisions. A structured and patient-centred approach ensures effective evaluation and appropriate care.
Watch our video below for a demonstration of a headache history.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Site:
Is the pain frontal, occipital, temporal, unilateral, or diffuse?
2. Onset, duration, and characteristics of the pain?
3. Started suddenly, gradually and any warning signs present?
If over seconds, think subarachnoid haemorrhage or meningitis
4. Nature of the pain (sharp, dull, throbbing)?
5. Radiation?
7. Timing
When the headaches began, their frequency, and duration, and when the last headache occurred?
8. Exacerbation or relieve the pain, such as coughing, lying down, or specific activities.
9. Severity:
Rate severity on a scale of 1-10 (e.g., mild, moderate, severe)
10. Explore red flags
Fever - Meningitis
Recent trauma - Traumatic Haemorrhage
Arm or leg weakness - Stroke?
Visual disturbances, or sensitivity to light and noise - Raised intracranial pressure e.g. space-occupying lesion, haemorrhage or meningitis
Nausea & vomiting - Raised intracranial pressure e.g. space-occupying lesion
Neck stiffness or rash - Meningitis
Pain when chewing or combing hair, or shoulder pain are signs of inflammatory conditions - Giant cell arteritis
ICE: Ideas, Concerns, Expectations
Ideas: What do they think is causing the headache?
Concerns: Are they worried about anything specific?
Expectations: What are they hoping for in terms of treatment?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
NSAIDs, aspirin or anticoagulants
Family History
Family history of bleeding disorders and polycystic kidney disease
Social History
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Occupation: Stress?
Recreational Drugs
Be sure to explore lifestyle factors such as sleep, stress, caffeine and water intake.
Differential Diagnosis
Headaches can be caused by the following causes:
Migraines: severe, throbbing, unilateral headache with visual or sensory aura.
Tension headaches: bilateral, associated with stress, and described as a tight band across the head
Cluster headaches: localised around one eye and occurring in clusters.
Sinusitis: causes a dull ache over the sinuses, worsened by bending forward.
Meningitis: associated with fever, neck stiffness, photophobia, rash.
Subarachnoid haemorrhage: sudden thunderclap headache.
Temporal arteritis: severe headache in the temple, jaw pain, and scalp tenderness.
Raised Intracranial Pressure: causes morning headaches, worsened by coughing or lying down, often with visual disturbances.
Management
Bedside:
Physical examination including
Neurological examination.
Ophthalmoscopy for papilledema.
Laboratory:
Blood Tests: FBC, U&Es, CRP, and ESR.
Imaging and Special Tests:
Temporal artery biopsy may be needed for suspected temporal arteritis.
Imaging with CT or MRI can identify structural causes.
Lumbar puncture may be required if meningitis or raised intracranial pressure is suspected.
Management Plan
Hydration and analgesia.
Migraines are treated with triptans and trigger avoidance.
Cluster headaches respond to oxygen and triptans, with prophylactic options like verapamil.
Meningitis requires IV antibiotics.
Intracranial haemorrhage may necessitate surgical intervention.
Temporal arteritis is treated with high-dose steroids to prevent complications like blindness.
Raised intracranial pressure, elevate the head of the bed, consider mannitol, and manage underlying causes.