What history should be taken for a patient with headaches and neurological deficits?

History-Taking for Headaches with Neurological Deficits

When a patient presents with headaches and neurological deficits, immediately assess for red flag features that indicate secondary causes requiring urgent investigation, focusing on the temporal pattern, associated symptoms, and specific neurological findings. 1, 2

Critical Red Flags to Identify Immediately

Temporal Pattern Red Flags

• Thunderclap headache (sudden onset reaching maximum intensity within seconds to minutes) suggests subarachnoid hemorrhage 1, 2
• "Worst headache of life" with abrupt onset indicates serious vascular pathology 2
• Progressive worsening pattern may indicate intracranial space-occupying lesion 1, 2
• Headache awakening patient from sleep raises concern for increased intracranial pressure 3, 1, 2
• New headache onset after age 50 suggests secondary headache and consideration of temporal arteritis 2
• Marked change in previously stable headache pattern is a red flag for secondary headache 2

Neurological Deficit Characterization

• Focal neurological symptoms or signs (weakness, sensory changes, visual disturbances) strongly suggest secondary headache requiring neuroimaging 1, 2
• Atypical aura (lasting >60 minutes, motor weakness, or without subsequent headache) may indicate transient ischemic attack, stroke, epilepsy, or arteriovenous malformations 1, 2
• Uncoordination may indicate cerebellar pathology 2
• Impaired memory, altered consciousness, or personality changes suggest secondary headache 1, 2

Associated Symptoms Requiring Investigation

• Neck stiffness suggests meningitis or subarachnoid hemorrhage 1, 2
• Unexplained fever indicates possible meningitis 1, 2
• Weight loss and/or change in memory or personality strongly suggests secondary headache 1, 2
• Headache worsened by Valsalva maneuver, coughing, sneezing, or exercise may suggest intracranial hypertension or space-occupying lesion 1, 2

Essential Historical Elements

Headache Characteristics

• Age at onset of headache symptoms 3
• Duration of individual headache episodes (4-72 hours suggests migraine; 15-180 minutes suggests cluster headache) 3, 4
• Frequency of headache episodes (≥15 days/month for >3 months suggests chronic migraine) 3
• Time of day headaches occur 3
• Location (unilateral vs bilateral; frontal, temporal, occipital, periorbital) 3
• Quality (throbbing/pulsating vs pressing/tightening) 3
• Severity (mild, moderate, or severe intensity) 3

Aggravating and Relieving Factors

• Worsening with routine physical activity (suggests migraine) 3
• Effect of lying still in dark, quiet room (relief suggests migraine) 4
• Relationship to posture changes 2
• Triggers: stress, weather changes, odors (perfume, chemicals, smoke), sexual activity 3

Associated Symptoms

• Photophobia and phonophobia (suggests migraine) 3
• Nausea and/or vomiting (suggests migraine) 3
• Autonomic symptoms (lacrimation, nasal congestion, rhinorrhea, ptosis, miosis, eyelid edema) suggest cluster headache 3, 4
• Aura symptoms: visual, sensory, speech/language, motor, brainstem, or retinal disturbances 3
• Aura timing: gradual spread over ≥5 minutes, duration 5-60 minutes, relationship to headache onset 3

Medication History

• Current acute medications and their effectiveness 3
• Frequency of acute medication use (≥10 days/month for triptans/ergots or ≥15 days/month for analgesics suggests medication-overuse headache) 3, 1
• Previous preventive medications tried 3
• Over-the-counter medications, natural remedies, or herbs 3

Contextual Factors

• Relationship to meals (recent food intake or missed meals) 3
• Foods and beverages consumed within 24 hours 3
• Sleeping patterns and quality 3
• In women, relationship to menstrual cycle 3
• Location when headaches occur (home, office, etc.) 3

Past Medical and Family History

• Family history of migraine (strongly supports migraine diagnosis) 3
• History of head or neck trauma 2, 5
• Previous headache evaluations and results 3
• Comorbid conditions: epilepsy, affective/anxiety disorders, connective tissue disorders, cancer, HIV infection 3, 5

Specific Secondary Causes to Screen For

Medication-Overuse Headache

• Most common secondary cause in patients with progressively worsening migraines 1
• Document frequency and duration of all acute headache medication use 3, 1

Giant Cell Arteritis

• Age ≥50 years with new headache 1
• Temporal artery tenderness or decreased pulse 1
• Associated jaw claudication or visual symptoms 1

Idiopathic Intracranial Hypertension

• Obesity or recent weight gain 1
• Visual disturbances (transient visual obscurations, diplopia) 1
• Pulsatile tinnitus 1

Obstructive Sleep Apnea

• Snoring, witnessed apneas, daytime somnolence (modifiable risk factor worsening migraine frequency) 1

Ottawa SAH Rule Application

For alert patients >15 years with new severe nontraumatic headache reaching maximum intensity within 1 hour, investigate for subarachnoid hemorrhage if ANY of the following:

• Age ≥40 years 2
• Neck pain or stiffness 2
• Witnessed loss of consciousness 2
• Onset during exertion 2
• Thunderclap headache (instantly peaking pain) 2
• Limited neck flexion on examination 2

Common Pitfalls to Avoid

• Do not rely solely on patient's self-diagnosis from internet sources; systematically apply diagnostic criteria 3
• Do not dismiss atypical features that don't fit classic migraine patterns; these warrant lower threshold for investigation 3
• Do not overlook medication-overuse headache in patients with increasing headache frequency despite treatment 3, 1
• Do not assume normal neuroimaging excludes all secondary causes; MRI is more sensitive than CT for structural abnormalities 1