What ROS (Review of Systems) questions should be asked for a patient presenting with a headache?

Essential Review of Systems Questions for Headache Evaluation

A thorough review of systems for patients presenting with headache should include specific questions about headache characteristics, associated symptoms, and red flag features to distinguish between primary and secondary headache disorders.

Headache Characteristics

• Frequency and timing:

  • How frequent are the headaches? 1
  • What time of day do they occur? 1
  • Do they awaken you from sleep? 1, 2
  • In women, do they occur during the menstrual cycle? 1

• Pain characteristics:

  • What is the character of the pain: dull, aching, throbbing, piercing, squeezing, excruciating? 1
  • Where is the pain located? One or both sides of the head? Front or back? Over or behind one eye? 1
  • How long do the headaches last? Hours, days? 1
  • Is this the worst headache of your life or did it have sudden/abrupt onset? 2, 3

Associated Symptoms

• Neurological symptoms:

  • Do you experience any visual changes, numbness, weakness, or speech difficulties? 1, 2
  • Are your senses affected (eyesight, hearing, touch)? 1
  • Do you experience dizziness? 1

• Autonomic symptoms:

  • Do you experience nausea or vomiting with the headache? 1, 3
  • Do you have sensitivity to light (photophobia) or sound (phonophobia)? 1
  • Do you experience tearing, nasal congestion, or facial sweating? 1

Red Flag Features

• Concerning patterns:

  • Is there a marked change in your headache pattern? 1, 2
  • Is the frequency or severity of headaches rapidly increasing? 1, 2
  • Does the headache worsen with Valsalva maneuver, coughing, or physical exertion? 2, 4
  • Did the headache occur following head trauma? 1, 2
  • Do the headaches occur during sexual activity? 1

• Age and medical history:

  • Is this a new headache after age 50? 2, 4
  • Do you have a history of cancer or are you immunocompromised? 2, 4
  • Is there a family history of headaches? 1

Treatment History

• Current and past treatments:
  • Do you take over-the-counter medications for your headaches? 1
  • Has another doctor prescribed medication? Does it work and for how long? 1
  • Do you take any natural remedies or herbs? 1
  • Have you ever been evaluated for these headaches? If so, what was the result? 1

Environmental and Lifestyle Factors

• Triggers and associations:
  • Where are you when the headaches occur? (Home, office, etc.) 1
  • Are you under stress when these headaches occur? 1
  • What is the weather like when the headaches occur? 1
  • Are you exposed to any odors such as perfume, chemicals, or smoke? 1
  • Have you eaten a meal or snack recently, or missed a meal? 1
  • What foods and beverages did you consume in the past 24 hours? 1
  • What are your sleeping patterns? 1

Postural Factors

• Position-related symptoms:
  • Does changing your position affect the headache? 4
  • Does lying down or standing up make the headache better or worse? 4

By systematically addressing these questions during the review of systems, clinicians can better differentiate between primary headache disorders (migraine, tension-type, cluster) and potentially dangerous secondary causes that require urgent evaluation and management.