What is the first step when a patient complains of a headache?

First Step in Headache Evaluation

The first step when a patient complains of headache is to perform a thorough history taking and physical examination to distinguish between primary and secondary headaches, and to identify red flags that may indicate a more serious underlying condition. 1

Initial Assessment: Focus on Red Flags

When evaluating a patient with headache, prioritize identifying these red flags that warrant urgent attention:

• "Worst headache of life"
• New headache pattern after age 50
• Headache worsened by Valsalva maneuver
• Headache that awakens patient from sleep
• Headache with focal neurological deficits
• Recent head or neck injury
• Abrupt onset headache
• Headache associated with exertion or sexual activity
• Systemic signs/symptoms (fever, weight loss)
• Secondary risk factors (cancer, HIV) 1, 2

Key Components of History Taking

1. Headache characteristics:

   • Location (unilateral vs. bilateral)
   • Quality (pulsating, throbbing, pressure)
   • Intensity (mild, moderate, severe)
   • Duration (hours, days)
   • Frequency (episodic vs. chronic)
   • Aggravating/alleviating factors
   • Associated symptoms (nausea, vomiting, photophobia, phonophobia)

2. Timing and pattern:

   • New vs. recurrent headache
   • Acute vs. gradual onset
   • Progression pattern
   • Relationship to activities or time of day

Focused Neurological Examination

The American Academy of Neurology recommends a complete neuro-ophthalmologic examination including:

• Visual acuity testing
• Visual field testing
• Fundoscopic examination
• Extraocular movement assessment
• Pupillary responses 1

Additionally, perform:

• Mental status assessment
• Cranial nerve examination
• Motor and sensory testing
• Deep tendon reflexes
• Coordination testing
• Meningeal signs

Decision Algorithm After Initial Assessment

Based on the American Academy of Family Physicians recommendations:

1. If red flags present:

   • Urgent neuroimaging (MRI with contrast preferred over CT for non-emergent situations)
   • Consider referral to emergency department or neurology

2. If no red flags and pattern suggests primary headache:

   • Classify according to International Headache Society criteria
   • Initiate appropriate treatment based on headache type and severity

Common Pitfalls to Avoid

• Failure to identify secondary headaches
• Overlooking medication overuse headache
• Misdiagnosis of migraine
• Inadequate treatment leading to chronic daily headache 1

Remember that while most headaches are benign primary headache disorders, missing a serious secondary cause can lead to significant morbidity and mortality. The history and physical examination are the most critical tools in making this distinction.