Taking a great headache history

In this video, you'll learn how to take an in-depth headache history and quickly identify the red flags that point to a secondary cause for your patient's headache.

Robert Coni, DO EdS
Robert Coni, DO EdS
13th Aug 2020 • 3m read

Become the Sherlock Holmes of headaches with this video from our Headaches Masterclass! You'll learn how to take an in-depth headache history by factoring in crucial information such as headache triggers, medication use, and recent procedures, as well as how to quickly identify the red flags that point to a secondary cause for your patient's headache.

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Our Headaches Masterclass course outlines an approach that will guide your evaluation of the patient with headache. It will provide you with the knowledge and skills you need to recognize and categorize primary headaches accurately, warning signs of ominous headaches (and those caused by medical conditions), and will teach you how to help your patients to help themselves by recognizing triggers and adopting lifestyle changes.

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Video transcript

A great headache history allows you to tease out the triggers which can be responsible for your patients headaches. Often there may be symptoms before, during, or after the headache pain, which the patient does not associate with their headaches. These symptoms may include aura symptoms.

Other signs may be photosensitivity, phonosensitivity, nausea and possibly vomiting. Is their scalp tenderness and pain with chewing or jaw claudication? If the patient can recognize headache triggers, they might be able to avoid the triggers and prevent the headaches. Some common triggers include menstruation, stress, skipping meals, or changes in sleep patterns, weather, environmental odors, lights, chemicals, coughing, bending, or certain foods, or other possible triggers.

It is important to ask about pharmacologic as well as non-pharmacologic factors, which alter the headache course. When asking about headache medications, be sure to inquire about frequency taken, dosage, as well as efficacy. What is the effect of rest and sleep? How about hot or cold compresses? Laying down versus being up and pacing?

In female patients inquire if there was a change in menopause, or pregnancy. Don't forget other historical data, a patient's marital status, work, education, and outside activities may provide important clues in determining the source of headache and in amelioration of headaches. Also inquire about other habits Including alcohol, tobacco, caffeine, and illicit drugs.

Family history is important since many headache disorders are familiar. For instance, almost 60% of migraineurs have a parent with a history of migraine. As many as 80% have a first degree relative with migraine. It is best to inquire specifically about the headache characteristics of family members if the patient can provide such detail, but it's even better if the family member can give the details in person.

Often I will see a patient in her 40s who relates that she had headaches in her late teens or perhaps early 20s, which were different and then went away. Seeking information about prior headaches and exploring differences from the current presentation might reveal that the patient now has similar headaches with premonitory symptoms, or an aura which is you unique for her.

Finding out how headaches have been treated in the past, including the doses and types of medications used, may aid in developing an updated treatment plan for the patient. Information about prior diagnostic testing can avoid unnecessary expense and substantiate the patient's impressions about what was found.

It is particularly important to know if they had a lumbar puncture, which can lead to low cerebral spinal fluid pressure, and a headache. Don't neglect how the headache affects the patient's work, overall function and their activities. Assess if the patient has had cancer, stroke, head injury, or other trauma, sinus disease, or dental disease.

HIV history should be noted as it can cause headaches with intracranial infections such as fungal meningitis or tuberculosis, and malignancy, such as central nervous system lymphoma. Epilepsy may be associated with symptoms that mimic migraine aura and seizure events can provoke headache called the Ictal epileptic headache.

Don't forget to review the red flags with your patient to rule out potentially dangerous causes of secondary headache, systemic signs and symptoms, neurologic abnormalities, sudden onset, older patient, progressive and P word characteristics, positional and papilledema. Conducting a thorough history of the patient's headaches will give you a better idea of the possible causes and treatments.