Headache History

Aka: Headache History, Headache Evaluation

1. See Also
   1. Headache
   2. Headache Red Flag
   3. Headache Causes
   4. Headache Examination
   5. Headache Diagnostic Testing
   6. Neuroimaging in Headache
2. Approach
   1. Consider Headache diary
      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 to chronic Headache patterns
      3. Identify Organic Headaches (see Headache Red Flags)
      4. Identify Medication Overuse Headache
3. 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)
4. 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
      2. CNS Infection (Meningitis, Encephalitis, Brain Abscess)
   5. Headache onset
      1. Gradual onset suggests benign cause
      2. Severe, sudden onset (Thunderclap Headache) is a Headache Red Flag
   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
5. 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
6. 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 Headache
      1. Acute Sinusitis
      2. Migraine Headache
   4. Pressure Headache
      1. Tension Headache
7. 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
8. History: Associated Symptoms or Signs
   1. Concurrent mental health concerns (e.g. Anxiety)
      1. Tension Headache
   2. Stress provokes Headache
      1. Tension Headache
      2. Migraine Headache
   3. Aura or prodrome
      1. Migraine Headache
      2. Seizure Disorder
   4. Lacrimation, Rhinorrhea and facial Flushing
      1. Cluster Headache
   5. Myalgias or Arthralgias
      1. Temporal Arteritis (Polymyalgia Rheumatica)
   6. Exertional Headache
      1. Organic Headache (Intracranial Mass)
      2. Benign Exertional Headache
   7. Recent Head Trauma
      1. Intracranial Hemorrhage (e.g. Subdural Hematoma)
      2. Post-Concussion Syndrome
   8. Vision related symptoms
      1. Temporal Arteritis
      2. Glaucoma
      3. Migraine Headache (scotomata, photophobia)
   9. Vomiting
      1. Migraine Headache (Nausea)
      2. Increased Intracranial Pressure (no Nausea)
   10. Facial tic
       1. Trigeminal Neuralgia
9. 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. 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
10. 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