Headache History

Introduction –WIPPP
• Wash hands
• Introduce yourself and confirm the patient’s name, age
• Privacy: Insure patient’s Privacy
• Permission: Gain consent with explaining what you are going to do.
• Pain: ask if the patient is currently in pain.
Presenting complaint (PC)
• What brought you to the clinic (or ER)?
• Age: temporal arteritis in old people
History of presenting complaint (HBC)
A) Analysis of pain (SOCRATES)
• Site: Where exactly is the pain?
o Exact site: front, temporal, occiptal
▪ Face/in front of ear  (Trigeminal neuralgia)
▪ Temporal  (temporal arteritis)
▪ Unilateral (Migraine), or bilateral  tension headache
• Onset: When did it start?
o Constant or intermittent?
o Gradual or sudden? (Sudden  Subarachnoid hemorrhage), (slowly progressive 
migraine) (progressive  subdural hematoma)
o Periodic (e.g. every month), correlation with menstruation
• Character: What is the pain like e.g. dull, pressure, burning, throbbing?
o Throbbing  Migraine
o Thunder-like  Subarachnoid hemorrhage
o Tight  tension headache
• Radiation: Does the pain radiate/move anywhere? (Neck  Subarachnoid hemorrhage)
o neck (meningitis) / face (e.g. trigeminal neuralgia) / eye (e.g. acute closed angle
glaucoma)
• Associations: Is there any symptoms that present before or with the headache? And for
how long does it last?
o (Migraine):
▪ Nausea, vomiting, phonophobia
▪ Visual disturbances:
• positive symptoms (e.g. scintilla (flash light), scotomas (blind spots), scintillating
scotoma (zigzag lines))
o (Cluster headache): ipsilateral nasal congestion, lacrimation, periorbital pain, eye redness,
rhinorrhea, and Horner's syndrome
o (Temporal arteritis): dizziness, blurred vision, jaw claudication, proximal limb pain
o (Sinusitis): facial pain, anosmia, fullness behind eye and cheeks, postnasal drip, rhinorrhea
o (Meningitis)  Photophobia, fever, stiff neck and rash
o Increased ICP nausea, projectile vomiting, decreased LOC, weakness, seizures…
o Transient loss of consciousness  If the patient lost consciousness, take history from witness
of symptoms before during and after the TLOC
• Time course:
o Diurinal variation: early morning headache  Increased ICP
o Duration of headaches (with or without Treatment)
o How long did it last before it reached its maximum pain?
o Duration of pain-free periods
 • Exacerbating/relieving factors:
o Exacerbating:
▪ Touching scalp (temporal arteritis)
▪ Cough, straining/bending down/coughing  Increased ICP
▪ Light, noise, activity (migraine, meningitis)
▪ Sexual activity?
▪ Specific types of food
o Relieving:
▪ Rest, medication, sitting in the dark.
▪ Persistent headache not responsive to analgesics  tension headache
• Severity;
o How severe is the pain? consider using the 1-10 scale.
o Does it affect daily life? Awakens the patient from sleep?
B) Red Flags
a. Recent Trauma
b. Focal Neurological symptoms; speech difficulty, weakness, numbness, Loss of consciousness
c. Vomiting
d. Worse in the morning/on waking up
e. Sudden onset
f. Fever
g. Scalp tenderness
h. Past medical history of cancer or HIV

Differential diagnoses of headache

Intracranial Extracranial Systemic
• Inflammation: Referred pain from eyes, ears, • HTN
o Meningitis nose, sinuses or teeth • Hypoglycemia
o Encephalitis • Fever
o Cerebral abscess • Drug-induced e.g. triptan,
painkillers
• Vascular: • Psychogenic
o Migraine
o Temporal arteritis
o Cluster headache

• Increased ICP
• Brain tumor
 1- Past medical
• Previous episodes of headache. Is it the same or worse? (IF Dxed w/ headache ask about meds
compliance)
• Head trauma
• Recovered visual loss (Multiple Sclerosis)
• Stroke
• Chronic diseases, e.g. diabetes, hypertension
• Malignancy

2- Past surgical history (PMH)

• Have you undergone any type of surgeries?

3- Drug history (DH)

• Find out what medications the patient is taking, dosage, specifically ask about:
o Analgesics (overuse?  rebound headache)
o Oral Contraceptives  when stopped menstrual-related headache, migraine.

• Allergies
• Vaccination history  bacterial meningitis

4- Family history (FH)

• Does anyone in your family have similar complain?
• Conditions within the family. Is there any condition that runs in your family, including chronic diseases?
o Migraines (‫)الشقيفي‬ o Malignancy

5- Social history (SH)

▪ Smoking
▪ Diet and caffeine intake
▪ Sleep
▪ Occupation
▪ Does he use any illegal substances, eg alcohol, cannabis, cocaine, etc.
▪ Stressors: (financial, occupational, relationship)
6- Systemic review (see appendix)
7- Concluding the interview

Ideas – what are the patient’s thoughts regarding their symptoms?

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
Is there anything else you would like to talk about? Then thank the patient