Comprehensive Headache History-Taking Checklist
The most effective approach to headache evaluation requires a systematic history-taking process that identifies red flags and distinguishes between primary and secondary headache disorders. 1
Essential Components of Headache History
Pain Characteristics
- Location: One or both sides of head? Front or back? Over or behind one eye? 2
- Quality: Pulsating/throbbing? Pressure-like? Sharp? Stabbing? 1
- Intensity: Mild, moderate, or severe? Impact on daily activities? 1
- Duration: How long do individual headaches last? (hours, days) 2
- Pattern: Continuous or intermittent? 1
Timing and Onset
- When did headaches first begin? 1
- How did they start? (gradual vs. sudden onset) 1
- Frequency of headaches (episodic vs. chronic) 1
- Time of day when headaches typically occur 2
- Do headaches awaken you from sleep? 2
Associated Symptoms
- Nausea and/or vomiting 1
- Photophobia (sensitivity to light) 1
- Phonophobia (sensitivity to sound) 1
- Visual disturbances or aura (describe specific symptoms) 1
- Other sensory changes (numbness, tingling) 2
Aggravating and Alleviating Factors
- What triggers the headaches? 2
- Stress or emotional factors
- Environmental factors (weather changes, odors, perfumes, chemicals, smoke)
- Food or beverages (within past 24 hours)
- Missed meals
- Physical activity
- Sexual activity
- What makes the headache worse? 1
- Movement or physical activity
- Coughing, straining, Valsalva maneuver
- Positional changes
- What relieves the headache? 2
- Rest/sleep
- Medications (effectiveness, duration of relief)
- Non-pharmacological measures
Red Flag Assessment
Critical for identifying potentially serious secondary headaches
- Sudden onset ("thunderclap" headache reaching maximum intensity within seconds to minutes) 1
- New headache after age 50 1
- Change in headache pattern or progressively worsening headaches 1
- Headache awakening patient from sleep 2
- Headache triggered by Valsalva maneuver, cough, exertion, or sexual activity 1
- Neurological symptoms (focal deficits, altered mental status) 1
- Systemic symptoms (fever, neck stiffness, rash) 1
- Headache following trauma 1
- Headache in patients with cancer, immunosuppression, or pregnancy 1
Medication and Treatment History
- Current and previous headache medications 2
- Prescription medications
- Over-the-counter medications
- Natural remedies or herbs
- Effectiveness of treatments 2
- Frequency of medication use (to identify possible medication overuse headache) 1
- Other current medications 1
Medical History
- Previous headache diagnoses or evaluations 2
- History of head or neck trauma 1
- Comorbid conditions (especially cardiovascular, psychiatric, or neurological) 2
- For women: Relationship to menstrual cycle, pregnancy, or hormonal contraceptives 1
Family and Social History
- Family history of headaches or neurological disorders 2
- Occupation and work environment 2
- Sleep patterns and disturbances 2
- Caffeine intake 2
- Alcohol and substance use 1
- Stress levels and coping mechanisms 2
Impact Assessment
- Effect on daily activities and functioning 1
- Work/school absences due to headache 1
- Psychological impact (anxiety, depression) 1
Contextual Information
- Where are you when headaches occur? (home, office, etc.) 2
- What are you doing when headaches begin? 2
Documentation Guidelines
- Document frequency, intensity, and duration of headaches 1
- Note all red flag symptoms 1
- Record response to previous treatments 2
- Consider using headache diaries or calendars for ongoing assessment 1
This systematic approach to headache history-taking helps differentiate between primary headache disorders (migraine, tension-type, cluster) and potentially dangerous secondary headaches requiring urgent evaluation and neuroimaging 1. Remember that diagnosis of primary headaches is primarily clinical based on established criteria, while secondary headaches require appropriate investigation based on identified red flags 1.