Accurately classify headaches with these questions
Perhaps the most important aspect of headache care is accurately diagnosing your patient’s headache type.
An appropriate diagnosis begins with applying what we know about the patient to a framework for headache classification: The International Headache Society’s International Classification of Headache Disorders Version 3 (ICHD-3), updated in 2018. This document can be accessed online and is used to differentiate primary and secondary headache disorders.
An accurate diagnosis allows you to devise the most effective plan of management for your patient’s condition and presentation. First, you must get your patient to describe, in detail the factors that distinguish their headache by taking a headache history.
There are eight characteristics you need to know in order to accurately classify your patient’s headache:
- Frequency and timing
- Pain characteristics
Let’s take a look at each in detail.
1. Onset of headache(s)
Sometimes when the patient is focused on the current presentation, you might have to dig to find out what the headaches were like at the beginning.
How do the headaches begin?
Have the patient describe any factors associated with the onset of the headache. Some activities that might bring on a headache include intercourse, Valsalva maneuver, or bending over.
2. Location of headache(s)
Are the headaches frontal or occipital? Or holocranial, or encompassing the whole head?
Is the pain always in the same place or does it move around?
Either from headache to headache or during a headache?
3. Duration headache(s)
How long do your headaches last? This information is important to help distinguish the type of headache. Migraines may last many hours while cluster headaches may be much shorter, usually less than three hours. Some other types of headache, such as ice-pick headaches or short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT), may last only minutes or even seconds.
4. Frequency and timing of headache(s)
Do the headaches occur daily, multiple times daily, or monthly? Cluster headaches may occur many times daily, on a seasonal basis, for weeks at a time. Alternatively, migraine might occur monthly, perhaps in association with menstruation.
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5. Intensity of headache(s)
Have your patient grade the severity of their headaches from one to ten. Use a numeric scale or a visual scale to help with this.
6. Pain characteristics of headache(s)
It is also important for your patient to describe the quality and character of their headache pain. Is the pain steady or throbbing? Is it a stabbing pain, shock-like or burning?
7. Course of headache(s)
Did it get inexorably worse? Did the pain build over hours or minutes?
8. History of headache(s)
It might be interesting for you to explore how long your patient has suffered from headaches, and, what drove them to your care at this time. Headache is often suffered in silence and we tend to minimize its impact on our lives. We say we don’t have time for this. However, headache unchecked can become chronic and worsen over time.
Here's a handy downloadable summary of the eight headache characteristics you need to know in order to accurately categorize and diagnose your patient’s headaches.
That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.
- Migraine Buddies App. https://app.migrainebuddy.com/
- Rizzoli P and Mullally, WJ. 2018. Headache. Am J Med. 131: 17–24. PMID: 28939471
- Turner, DP, Jchtay, I, Lebowitz, A, et al. 2018. Perceived migraine triggers. Practical Neurology. 17: 37–40.
- Young, WB, 2018. The stigma of migraine. Practical Neurology. 17: 23–26.
- Young, WB, Silberstein, SD, Nahas, SJ, et al. 2011. Jefferson Headache Manual. New York: Demos Medical Publishing.