What history should be taken from a patient presenting with a headache?

Headache History Assessment

When evaluating a patient with headache, systematically obtain temporal characteristics, pain features, accompanying symptoms, medication use, and screen for red flags that indicate life-threatening secondary causes requiring urgent intervention. 1

Temporal Pattern and Episode Characteristics

• Age at onset: Migraine typically begins at or around puberty, while new-onset headache after age 50 years raises concern for giant cell arteritis, stroke, or tumor 1, 2

• Duration of individual episodes: Migraine lasts 4-72 hours, cluster headache 15-180 minutes, and tension-type headache has variable duration 1, 3

• Frequency: Document whether headaches occur episodically or ≥15 days per month (suggesting chronic migraine or medication-overuse headache) 1, 2

• Time of day: Ask if headaches wake the patient from sleep (suggesting increased intracranial pressure or secondary causes) or occur at specific times 1, 2

• Onset pattern: Sudden "thunderclap" or "worst headache of life" suggests subarachnoid hemorrhage requiring immediate CT within 6 hours 1, 2

Pain Characteristics

• Location: Unilateral pain occurs in migraine and cluster headache, while bilateral pain suggests tension-type headache 1, 3

• Quality: Pulsating quality indicates migraine, pressing/tightening suggests tension-type, and severe unilateral pain characterizes cluster headache 1, 3

• Severity: Moderate-to-severe intensity occurs in migraine and cluster headache, while mild-to-moderate suggests tension-type 1

• Aggravating factors: Routine physical activity worsens migraine but not tension-type headache; Valsalva maneuver, cough, or exertion triggering headache suggests secondary causes like increased intracranial pressure 1, 4

• Relieving factors: Lying flat improving headache within 2 hours suggests spontaneous intracranial hypotension 1

Accompanying Symptoms

• Migraine-associated features: Nausea, vomiting, photophobia, and phonophobia occur with migraine 1, 2

• Aura symptoms: Visual disturbances (scintillating lights, zigzag lines), hemisensory symptoms (numbness, tingling), or speech difficulties lasting 5-60 minutes and developing gradually over ≥5 minutes suggest migraine with aura 5, 1, 2

• Autonomic symptoms: Ipsilateral lacrimation, conjunctival injection, nasal congestion, ptosis, or miosis accompanying severe unilateral headache indicates cluster headache 1, 3

• Neurological symptoms: Focal neurological deficits, altered consciousness, memory changes, or personality changes are red flags requiring urgent evaluation 1, 4

• Systemic symptoms: Unexplained fever with neck stiffness suggests meningitis; scalp tenderness and jaw claudication in patients >50 years suggests giant cell arteritis 1

Medication History

• Current acute medications: Document frequency of use—non-opioid analgesics ≥15 days/month or other acute medications ≥10 days/month for >3 months indicates medication-overuse headache 1, 2

• Preventive medications: Record all current and past preventive treatments and their effectiveness 2

• Over-the-counter medications: Include all self-prescribed analgesics, as these contribute to medication-overuse patterns 2

Red Flag Screening

• Recent trauma: Head or neck injury preceding headache onset 1, 4

• Progressive worsening: New headache or headache pattern that is progressively worsening over time 1, 4

• Atypical aura: Focal neurological symptoms suggesting stroke or TIA rather than typical migraine aura 1

• Cancer or immunosuppression: Secondary risk factors increasing likelihood of serious pathology 4, 6

• Pregnancy: Requires different diagnostic and treatment considerations 4

• Witnessed loss of consciousness: Suggests serious underlying pathology 1

Diagnostic Tools to Implement

• Headache diary: Have patients document frequency, duration, character, triggers, accompanying symptoms, and medication use to reduce recall bias and increase diagnostic accuracy 1, 2

• ID-Migraine questionnaire: Three-item screening tool with sensitivity 0.81 and specificity 0.75 for migraine diagnosis 1, 2

• Family history: Document family history of migraine, as it has strong genetic component with higher prevalence among first-degree relatives 1

• Menstrual cycle relationship: In female patients, ask whether headaches correlate with menstrual cycle 2

Common Pitfalls to Avoid

• Do not dismiss headaches that always occur on the same side—while less worrisome than other red flags, unilateral location is characteristic of migraine and cluster headache and requires proper classification 4

• ESR can be normal in 10-36% of giant cell arteritis cases, so clinical suspicion in patients >50 years with new-onset headache, scalp tenderness, or jaw claudication should prompt rheumatology referral even with normal ESR 1, 7

• Headaches waking patients from sleep, while concerning, are less worrisome than thunderclap onset, progressive worsening, or associated neurological symptoms, but still warrant thorough evaluation 4