What is the appropriate history and physical examination for a patient presenting with headache?

From the Guidelines

The appropriate history and physical examination for a patient presenting with headache should begin with a thorough history focusing on headache characteristics, including onset, location, quality, severity, duration, frequency, and alleviating or exacerbating factors, as outlined in the most recent guidelines 1.

History

The history should include:

• Age at onset of headache
• Duration of headache episodes
• Frequency of headache episodes
• Pain characteristics, such as location, quality, severity, aggravating factors, and relieving factors
• Accompanying symptoms, such as photophobia, phonophobia, nausea, and vomiting
• Aura symptoms, if any
• History of acute and preventive medication use, as recommended by 1
• Medical history, including previous headaches, trauma, hypertension, and recent infections
• Medication history, covering current analgesics, their effectiveness, and potential medication overuse
• Family history of migraines or other headache disorders

Physical Examination

The physical examination should include:

• Vital signs, particularly blood pressure
• A complete neurological examination, including mental status, cranial nerves, motor and sensory function, reflexes, coordination, and gait
• Fundoscopic examination to check for papilledema
• Palpation of the head and neck for tenderness
• Assessment of meningeal signs For patients with concerning features, such as sudden-onset severe headache, headache with fever, altered mental status, focal neurological deficits, or headache following trauma, further diagnostic testing like neuroimaging (CT or MRI) and possibly lumbar puncture may be warranted, as suggested by 1 and 1.

Red Flags

It is essential to identify "red flags" that may indicate a secondary cause of headache, such as:

• Sudden-onset severe headache
• Headache with fever
• Altered mental status
• Focal neurological deficits
• Headache following trauma If any of these "red flags" are present, further evaluation and diagnostic testing are necessary to rule out a secondary cause of headache, as recommended by 1.

Diagnosis

The diagnosis of chronic migraine can be made based on a patient's history and physical examination, using the simplified diagnosis proposed by 1, which includes:

• 15 or more headaches per month
• Each headache lasting at least 4 hours
• Headaches on 8 or more days per month associated with migraine features, with or without medication use However, it is crucial to consider the patient's overall clinical presentation and medical history when making a diagnosis, as emphasized by 1.

Management

The management of headache disorders should be individualized and based on the patient's specific needs and diagnosis, as outlined in the guidelines 1 and 1. This may include lifestyle modifications, medication, and referral to a specialist if necessary.

From the Research

History of Headache

• A focused history is important to identify secondary headache and determine whether an immediate referral to the emergency department or a non-emergent referral to the neurologist is warranted 2
• Key steps in taking a history include proper categorisation of the primary headache, attention to lifestyle and psychosocial factors 2
• A detailed history can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache 3
• Evaluation of acute headaches using a systematic framework such as the SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches 3

Physical Examination of Headache

• A physical examination is important to identify secondary headache and determine whether an immediate referral to the emergency department or a non-emergent referral to the neurologist is warranted 2
• A complete neurological examination is essential in the initial assessment of a headache patient 4
• Signs such as predictable timing, sensitivity to smells or sounds, family history of migraine, recurrent sinus headache, or recurrent severe headaches with a normal neurologic examination could indicate migraine headache 3
• Red flag signs or symptoms such as acute thunderclap headache, fever, meningeal irritation on physical examination, papilledema with focal neurologic signs, impaired consciousness, and concern for acute glaucoma warrant immediate evaluation 3

Diagnostic Approach

• A thorough history and physical examination, along with a comprehensive differential diagnosis may alert a physician to the diagnosis of a secondary headache particularly when it is accompanied by certain clinical features 4
• Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated 4
• Careful attention to the patients' history and physical examination will guide the diagnostic work-up and management 4
• Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging 3