Headache History

Aka: Headache History, Headache Evaluation

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II. Approach

  1. Consider Headache diary in chronic Headaches
    1. Should include Headache date, duration, symptoms, triggers, treatment and outcome
    2. https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/headache/diagnosis/headache-diary.html
  2. Key goals for Headache History
    1. Identify different Headache types (typical Headaches as well as new or changed Headache patterns)
      1. Many patients have both Tension Headaches and Migraine Headaches
    2. Identify episodic Headache and chronic Headache patterns
    3. Identify Organic Headaches (see Headache Red Flags)
    4. Identify Medication Overuse Headache

III. History: Headache Timing

  1. New, Chronic or Recurrent Headache
    1. Acute Headache
      1. Acute Generalized Headache
      2. Acute Localized Headache
      3. Acute Recurrent Headache
    2. Chronic Headache
      1. Chronic Progressive Headache
      2. Chronic Non-Progressive Headache
  2. Duration of chronic Recurrent Headaches
    1. Headache >4 hours
      1. Migraine Headache: 6 to 36 hours typical
      2. Tension Headache: Constant daily Headache
    2. Headache <4 hours
      1. Autonomic features
        1. Cluster Headache: 30 to 90 minutes
      2. No autonomic features
        1. Trigeminal Neuralgia
  3. Headache that awakens patient overnight
    1. Hypoxia (e.g. Sleep Apnea, COPD)
    2. Carbon Monoxide Poisoning
    3. Bruxism
    4. Drug Withdrawal (includes Caffeine)
    5. Migraine Headaches
    6. Cluster Headache
    7. Narrow Angle Glaucoma
    8. CNS Mass
    9. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

IV. History: Organic Headache Assessment

  1. See Headache Red Flag
  2. See Organic Headache
  3. See Acute Generalized Headache
  4. First or worst Headache? (Headache Red Flag)
    1. Intracranial Hemorrhage (e.g. Subarachnoid Hemorrhage)
    2. CNS Infection (e.g. Meningitis, Encephalitis, Brain Abscess)
  5. Headache onset
    1. Gradual onset suggests benign cause
    2. Severe, sudden onset (Thunderclap Headache) is a Headache Red Flag (e.g. Subarachnoid Hemorrhage)
  6. Age of Headache onset
    1. Under age 30 years is associated with lower risk Headaches
    2. Migraine Headaches rarely have onset after age 40 years

V. History: Headache localization and radiation

  1. Bilateral or Generalized
    1. See Acute Generalized Headache
    2. See Chronic Daily Headache (Tension Headache)
  2. Localized (more significant than generalized)
    1. See Acute Localized Headache
    2. Common primary unilateral Headaches
      1. Cluster Headache
      2. Migraine Headache
      3. Trigeminal Neuralgia
    3. Temporal forehead
      1. Temporal Arteritis
      2. Eye strain (especially with Astigmatism)
      3. Migraine Headache
    4. Trigeminal Nerve distribution
      1. Trigeminal Neuralgia
    5. Jaw pain
      1. Temporomandibular Joint Disorder
    6. Occipital pain
      1. Hypertension
      2. Tension Headache (usually Generalized Headache)
      3. Increased Intracranial Pressure
      4. Cervical Radiculopathy
      5. Occipital Neuralgia
    7. Eye Pain
      1. Acute Glaucoma
      2. Temporal Arteritis
      3. Acute Sinusitis
      4. Eye strain
      5. Occipital neuralgia due to Cervical Radiculopathy
      6. Cluster Headache
      7. Migraine Headache
    8. Lower face
      1. Trigeminal Neuralgia

VI. History: Headache Characteristics

  1. Pounding Headache
    1. Carbon Monoxide Poisoning
    2. Nitroglycerin or other Vasodilator medications
    3. Migraine Headache
  2. Lancinating Headache (sharp, stabbing pain)
    1. Trigeminal Neuralgia
    2. Occipital neuralgia due to Cervical Radiculopathy
    3. Ice pick Headache (Migraine variant)
    4. Cluster Headache
  3. Throbbing or Pulsatile Headache
    1. Acute Sinusitis
    2. Migraine Headache
  4. Pressure Headache
    1. Tension Headache

VII. History: Demographics

  1. Home environment
    1. More than one family member with acute Headache
      1. Carbon Monoxide Poisoning (until proven otherwise)
  2. Gender Predominance
    1. Male
      1. Cluster Headache
    2. Female
      1. Hormonal Headache (e.g. Menstrual Migraine)
      2. Basilar Migraine Headache (female adolescents)
  3. Age at Headache onset
    1. Young Child
      1. Hemiplegic Migraine Headache
      2. Ophthalmoplegic Migraine Headache
    2. Older Child, Adolescent and Young adult
      1. Migraine Headache
      2. Tension Headache
      3. Temporomandibular Joint Disorder
      4. Basilar Migraine Headache (female adolescents)
      5. Paroxysmal Hemicrania
        1. Similar to Cluster Headache without Lacrimation
      6. Cluster Headache (rare in children)
      7. Occipital Neuralgia
    3. Adult of middle age and older
      1. See Headaches due to Medication
      2. Temporal Arteritis
      3. Hypertension
      4. Intracranial Mass
      5. Cerebrovascular ischemia
      6. Cervical Radiculopathy (Cervical Spondylosis)
      7. Chronic Obstructive Pulmonary Disease
      8. Hypnic Headache

VIII. History: Associated Symptoms or Signs

  1. Review for Headache Red Flag
    1. Includes fever, Nuchal Rigidity, Thunderclap Headache, Exertional Headache
  2. Concurrent mental health concerns (e.g. Anxiety)
    1. Tension Headache
  3. Stress provokes Headache
    1. Tension Headache
    2. Migraine Headache
  4. Aura or prodrome
    1. Migraine Headache
    2. Seizure Disorder
  5. Lacrimation, Rhinorrhea and facial Flushing
    1. Cluster Headache
  6. Myalgias or Arthralgias
    1. Temporal Arteritis (Polymyalgia Rheumatica)
  7. Exertional Headache
    1. Organic Headache (Intracranial Mass)
    2. Benign Exertional Headache
  8. Recent Head Trauma
    1. Intracranial Hemorrhage (e.g. Subdural Hematoma)
    2. Post-Concussion Syndrome
  9. Neck spasm
    1. Tension Headache
    2. Differentiate from the Nuchal Rigidity of Meningitis
  10. Vision related changes (including photophobia)
    1. Temporal Arteritis
    2. Glaucoma
    3. Migraine Headache (scotomata, photophobia)
    4. Idiopathic Intracranial Hypertension (Diplopia due to CN 6 Palsy)
  11. Nausea or Vomiting
    1. Migraine Headache (Nausea)
    2. Increased Intracranial Pressure (no Nausea)
  12. Facial tic
    1. Trigeminal Neuralgia

IX. History: Modifying Factors

  1. Palliative Factors
    1. Headache relieved when removed from environment
      1. Carbon Monoxide Poisoning
    2. Sleep
      1. Migraine Headache
    3. Oxygen at 100% FIO2
      1. Cluster Headache
  2. Provocative Factors
    1. See Migraine Headache Triggers
    2. Exertion or Sex (red flag for Organic Headache)
      1. See Exertional Headache
      2. Migraine Headaches may also be exacerbated by activity
    3. Position Change
      1. Headaches worse in supine position
        1. Increased Intracranial Pressure
        2. Space occupying lesions
      2. Headaches worse when upright (sitting or standing)
        1. Spinal Headache
    4. Eye movement
      1. Migraine Headache
      2. Eye strain
      3. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
      4. Thyroid Eye Disease (Graves Orbitopathy)
      5. Optic Neuritis
    5. Menses
      1. Menstrual Migraine
    6. Current medications
      1. Analgesics, Ergotamines or Triptans on more than 10-15 days per month
        1. See Rebound Headache
      2. Other medication associated Headaches
        1. See Increased Intracranial Pressure Causes
        2. See Medication Causes of Headache

X. References

  1. Cutrer in Goldman (2000) Cecil Medicine, p. 2066
  2. Duman in Friedman (1991) Medical Diagnosis, p. 392-3
  3. Henry in Marx (2002) Rosen's Emergency Medicine, p. 152
  4. Pruitt in Goroll (2000) Primary Care Medicine, p. 931-9
  5. Tabatabai (2021) Emerg Med Clin North Am 39(1): 67-85 [PubMed]
  6. Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]

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