What questions should be asked when taking a medical history to evaluate headaches/migraines in a teenager?

Essential History Questions for Evaluating Headaches/Migraines in Teenagers

When evaluating a teenager with headaches, systematically document age at onset, duration, frequency, location, pain quality, severity, aggravating/relieving factors, accompanying symptoms, aura features, medication use, and family history—these elements are essential for applying diagnostic criteria and distinguishing primary from secondary headache disorders. 1

Core Temporal and Pattern Questions

Onset and Duration:

• At what age did the headaches begin? (Migraine typically starts at or around puberty) 1
• How long does each headache episode last? (Migraine: 4-72 hours; Cluster: 15-180 minutes; Tension-type: variable) 1, 2
• How often do headaches occur? (Episodic versus ≥15 days/month suggesting chronic migraine) 1
• What time of day do headaches occur? 1
• In female patients, do headaches occur during the menstrual cycle? 1

Pain Characteristics

Location and Quality:

• Where is the pain located—one side or both sides of the head, front or back, over or behind one eye? 1
• What is the character of the pain: dull, aching, throbbing, piercing, squeezing, or excruciating? 1
• How severe is the pain—mild, moderate, or severe? 1

Modifying Factors:

• Does routine physical activity (walking, climbing stairs) make the headache worse? 1
• Does lying flat improve the headache? (Suggests orthostatic/spontaneous intracranial hypotension) 2
• Does coughing, sneezing, or straining (Valsalva maneuver) worsen the headache? (Suggests increased intracranial pressure or secondary causes) 2, 3

Accompanying Symptoms

Migraine-Associated Features:

• Is there nausea or vomiting with the headache? 1
• Does light bother you during the headache (photophobia)? 1
• Does sound bother you during the headache (phonophobia)? 1
• Are there any visual disturbances, numbness, tingling, or speech difficulties before or during the headache? (Aura symptoms lasting 5-60 minutes) 1, 2

Cluster Headache Features:

• Is there tearing, eye redness, nasal congestion, or eyelid drooping on the same side as the headache? 1, 2

Medication History

Current and Past Use:

• What medications have you tried for the headaches, both over-the-counter and prescription? 1
• How often do you take acute headache medications? (≥15 days/month for non-opioid analgesics or ≥10 days/month for other acute medications suggests medication-overuse headache) 2
• Are you taking any preventive medications? 1

Red Flag Screening Questions

Critical Warning Signs:

• Was the onset sudden and severe, like a "thunderclap" or "worst headache of your life"? (Suggests subarachnoid hemorrhage) 2
• Does the headache wake you from sleep? (Suggests increased intracranial pressure or secondary causes) 2, 3
• Has there been recent head or neck trauma? 2
• Is there fever or neck stiffness? (Suggests meningitis) 2
• Are there any focal neurological symptoms like weakness, numbness, vision changes, or difficulty speaking? 2
• Has the headache pattern changed recently or become progressively worse? 2

Family and Social History

Genetic and Environmental Factors:

• Does anyone in your immediate family have migraines? (Migraine has strong genetic component; family history strengthens diagnosis) 1, 2
• What triggers seem to bring on the headaches? 2
• How do the headaches affect your daily activities, school attendance, and quality of life? 1

Diagnostic Tools to Consider

Screening Instruments:

• Use the ID-Migraine questionnaire (3 questions about nausea, photophobia, and disability; sensitivity 0.81, specificity 0.75) 1, 2
• Consider the Migraine Screen Questionnaire (5 questions; sensitivity 0.93, specificity 0.81) 1, 2
• Implement a headache diary to document frequency, duration, triggers, accompanying symptoms, and medication use—this reduces recall bias and increases diagnostic accuracy 1, 2

Common Pitfalls to Avoid

Diagnostic Errors:

• Don't dismiss bilateral headaches as "just tension-type"—migraine can be bilateral in teenagers 1
• Don't assume occipital location alone indicates secondary pathology—location alone is not diagnostic 4
• Don't overlook medication-overuse headache in teenagers using frequent over-the-counter analgesics 2
• Don't miss giant cell arteritis in patients over 50 years presenting with new-onset headache, scalp tenderness, or jaw claudication 2
• Remember that headache phenotype may not be fully developed in adolescents and can evolve over time 4