What questions should be asked in a medical interview for a patient presenting with headache?

Key Questions for Headache Evaluation in Medical Interviews

When evaluating a patient with headache, clinicians should focus on identifying red flags, characterizing the headache pattern, and assessing impact on quality of life through a structured set of targeted questions.

Essential Questions to Identify Red Flags

• Onset and timing:

  • "Was the onset of your headache sudden (seconds to minutes) or gradual?" 1
  • "Is this the worst headache of your life?" 1
  • "How long do your headaches typically last?" 2, 1
  • "Do you feel like you have headaches on 15 or more days per month?" 2

• Associated neurological symptoms:

  • "Do you experience any visual changes, numbness, weakness, or difficulty speaking with your headaches?" 1
  • "Have you had any changes in consciousness or mental status during headaches?" 1
  • "Do you experience nausea, vomiting, sensitivity to light or sound?" 1

• Post-trauma or exertional factors:

  • "Did the headache begin after a head injury or trauma?" 1
  • "Is the headache triggered or worsened by physical activity, coughing, or straining?" 1

• Systemic symptoms:

  • "Do you have fever, neck stiffness, or rash with your headaches?" 1
  • "Have you experienced unexplained weight loss or other systemic symptoms?" 3

Characterizing the Headache Pattern

• Location and quality:

  • "Where is the pain located? Is it on one side or both sides of your head?" 1
  • "How would you describe the pain? (pulsating, throbbing, pressure, stabbing)" 1
  • "On a scale of 1-10, how severe is the pain?" 1

• Temporal pattern:

  • "What time of day do headaches typically occur?" 4
  • "Do they wake you from sleep?" 3
  • "How frequently do you experience headaches?" 2
  • "Has the pattern of your headaches changed recently?" 3

• Triggers and relieving factors:

  • "What seems to trigger your headaches?" 1
  • "What makes your headaches better? (rest, medications, darkness)" 1
  • "Do certain foods, stress, hormonal changes, or environmental factors trigger your headaches?" 1

Medication and Treatment History

• Current and past medications:

  • "What medications do you take for your headaches? How often?" 1
  • "Have you been using over-the-counter pain medications regularly?" 4
  • "Have you tried preventive medications for headaches?" 2

• Response to treatment:

  • "How effective are your current treatments?" 2
  • "Have you experienced side effects from headache medications?" 2

Impact on Daily Life

• Functional assessment:
  • "How do these headaches affect your daily activities?" 1
  • "Do you miss work or school because of headaches?" 5
  • "How do headaches impact your sleep, mood, and relationships?" 1

Medical and Family History

• Comorbid conditions:

  • "Do you have any other medical conditions, especially cardiovascular, psychiatric, or neurological disorders?" 1
  • "Do you have high blood pressure, sleep apnea, or depression?" 2

• Family history:

  • "Does anyone in your family suffer from headaches or migraines?" 1
  • "Is there a family history of neurological disorders?" 1

• Lifestyle factors:

  • "Describe your sleep patterns, caffeine intake, and stress levels." 1
  • "What is your occupation and work environment like?" 1
  • "Do you use tobacco, alcohol, or recreational drugs?" 5

Why These Questions Matter

These questions are critical for distinguishing between primary headaches (migraine, tension-type, cluster) and secondary headaches caused by potentially life-threatening conditions. The American College of Radiology emphasizes that thunderclap headache, focal neurological deficits, altered mental status, neck stiffness, and headache following trauma are danger signs requiring immediate attention 1.

The International Classification of Headache Disorders (ICHD-3) requires specific criteria for diagnosing migraine, including pulsating quality, unilateral location, moderate/severe intensity, and aggravation by physical activity, along with nausea/vomiting or photophobia/phonophobia 1.

Common Pitfalls to Avoid

• Failing to recognize red flags that indicate need for urgent neuroimaging, which can delay diagnosis of serious conditions like subarachnoid hemorrhage 1
• Dismissing sentinel headaches that may precede catastrophic events 1
• Not documenting headache frequency accurately, leading to misdiagnosis of chronic migraine as episodic migraine 1
• Overlooking medication overuse headache in patients using analgesics regularly 1, 4
• Not using a headache diary to accurately track patterns, as patients often report only severe headaches but may forget milder ones 2

By systematically addressing these questions, clinicians can effectively evaluate headaches, identify those requiring urgent attention, and develop appropriate treatment plans that improve patient outcomes and quality of life.