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geekymedics.com /headache-history-taking/
2/20/2016
Headache is a common presenting complaint and certainly something youll encounter many times over your
career. The vast majority of headaches are not life threatening, with tension headache and migraine being the most
common diagnoses. Headache is however also associated with a number of serious conditions and therefore it is
essential you are able to take a comprehensive headache history and identify red flags that indicate the need for
further investigation. Check out the headache history taking OSCE mark scheme here.
Gain consent
Presenting complaint
Its important to use open questioning to elicit the patients presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Ok, so tell me more about that Can you explain what that pain was like?
Was the onset acute or gradual? (sudden onset thunderclap headache is suggestive
of subarachnoid haemorrhage)
Character aching / throbbing / pounding / pulsating / pressure / pins and needles / stabbing
Radiation neck (meningitis) / face (e.g. trigeminal neuralgia) / eye (e.g. acute closed angle glaucoma)
Associated symptoms:
Timing:
Duration of headache?
Is it episodic?
Any clear pattern?
Diurnal variation?
Chronic headaches in a month of 30 days, for how many of those days would the patient have a
headache?
Exacerbating factors are there any obvious triggers for the symptom? (e.g. caffeine / codeine / stress /
postural change)
Relieving factors does anything appear to improve the symptoms (e.g. improvement upon lying flat
2/5
suggestive of reduced ICP).
Severity:
Red flags
Red flags within a headache history are many and varied, so familiarise yourself with common patterns.
A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid
haemorrhage).
Fever with a worsening headache, meningeal irritation and change in mental status (viral / bacterial
meningitis).
New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial haemorrhage /
ischaemic stroke / space occupying lesion).
Decreased level of consciousness.
Head trauma (more significant if within the last three months).
Headache which is posture dependent (e.g. worse on lying down and coughing with raised ICP).
Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication
(temporal arteritis).
Headache associated with severe eye pain / blurred vision / nausea and vomiting / red eye (acute angle
closure glaucoma).
Concerns explore any worries the patient may have regarding their symptoms
Expectations gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if theres anything else that youve overlooked.
Continue to periodically summarise as you move through the rest of the history.
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Signposting
What you have covered Ok, so weve talked about your symptoms and your concerns regarding them
What you plan to cover next Now Id like to discuss your past medical history and your medications
History of malignancy?
Previous surgery? e.g. CSF shunting (blocked / infected shunts present with headache)
Drug history
Regular prescribed medication?
Family history
Neurological diagnoses in first degree relatives? e.g. migraine
Social history
Smoking How many cigarettes a day? How long have they smoked for?
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Alcohol How many units a week? be specific about type / volume / strength of alcohol
Living situation:
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
GI Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Summarise history
5/5