This is a UKMLA-centred history guide about headache.
Introduction
Headaches are a common symptom that you will come across in primary care, emergency departments and secondary care. There are a wide range of causes from benign to serious and life changing.
Presenting Complaint
Site
Unilateral – migraine, trigeminal neuralgia, cluster headache
Bilateral – tension headache
Behind the eyes – eye strain
Across the face in a strip – shingles, trigeminal neuralgia
Over temples or generalised scalp tenderness – temporal arteritis
Occipital – Subarachnoid haemorrhage
Quality/Character
Squeezing band around head – tension headache
Burning – trigeminal neuralgia
Pulsating – migraine, temporal arteritis
Intensity
– Sudden onset thunderclap headache that reaches maximum intensity within five mins is pathognomonic for a subarachnoid haemorrhage.
– Tension headaches tend to be mild.
– Migraines can be moderate to severe.
Timing
Duration? Constant? Intermittent? Frequency?
– Cluster headaches occur between one alternate days to eight times a day.
– Migraines last 4-72 hours.
– Medication overuse headaches occur on more than 15 days per month for three months and are often worse in the morning.
– Persisting and/or progressive headache over weeks can suggest intracranial pathology.
– Raised intracranial pressure headaches are classically worst in the mornings and ease up as the day goes on.
Associated Symptoms
– Nausea, vomiting, photophobia, phonophobia, and aura are all associated with migraines.
– Autonomic features ipsilateral lacrimation, eyelid swelling/drooping, rhinorrhoea, miosis, flushing and sweating are associated with cluster headaches.
– Vision changes can be suggestive of migraines, temporal arteritis, and acute glaucoma.
– New neurological symptoms, change in personality or change in cognition can suggest serious causes such as stroke, TIA, space occupying lesion and CNS infection.
– Dizziness can be associated with strokes.
Precipitating Events
– Exercise can precipitate subarachnoid haemorrhage and worsens hypertensive headaches.
– Head trauma within past three months can suggest concussion or subdural haemorrhage/haematoma.
– A change in glasses or prescription can cause eye strain.
– Stopping alcohol, certain medications and/or caffeine can precipitate withdrawal headaches.
Aggravating Factors
– Exercise will worsen concussion, intracranial pathology and raised intracranial pressure.
– Loud noises and bright lights worsen migraines.
– Dehydration worsens tension headaches.
Alleviating Factors
– Eating and drinking will improve dehydration headaches.
– Drinking caffeine will improve caffeine withdrawal headaches.
– Migraines will improve sitting in a quiet, dark room.
Loud noises and bright lights worsen migraines.
Differentials
There is a large amount of overlap between different causes of headaches. Key features of common differentials are summarised in the table below:
| Differential | Features |
|---|---|
| Tension Headache | Bilateral, band like pain, no additional features, can be triggered by stress and fatigue. |
| Migraine | Last 4-72 hours, unilateral, associated aura, nausea, photophobia, phonophobia. |
| Cluster Headaches | Unilateral, ipsilateral autonomic features, up to eight times a day, occur in clusters. |
| Medication overuse | History of medication for other primary headache disorder, more than 15 days per month for three months, often worse in the morning. |
| Subarachnoid Haemorrhage | Sudden onset, severe thunderclap headache, onset during exercise or sex. |
| Stroke / TIA | Associated focal neurology, dizziness, vision changes, weakness, slurred speech. |
| CNS Infection | Fevers, stiff neck, photophobia, reduced consciousness, immunocompromise. |
| Temporal Arteritis | Unilateral, vision changes, associated with PMR. |
| Eye Strain | Glasses, no recent checkup, working on computer makes it worse. |
| Hypertension | Often asymptomatic, late features are headaches and vision changes. |
| Intracranial pathology | Morning headaches and nausea, neurological features, behaviour change, reduced consciousness, cognition change, worse with exercise. |
| Caffeine | High caffeine intake, worse/better when consumes caffeine. |
| Glaucoma | Blurred vision, nausea, vomiting, halos around lights often unilateral. |
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history about headache, you can show how much you know about the various causes by explicitly asking about the following things:
Past Medical History
– Uncontrolled hypertension (can cause severe headaches and vision changes).
– Recent shingles infection (can lead to postherpetic neuralgia).
– Anticoagulants (predispose patients to subdural haematoma following head trauma).
– Immunocompromise (can predispose patients to CNS infections).
– Consider pre-eclampsia in pregnant patients.
– Does the patient wear glasses? When did they last have their eyes checked?
– Temporal arteritis is strongly associated with polymyalgia rheumatica (40% of patients with temporal arteritis have features of PMR).
Social History
Caffeine intake (overuse can cause both caffeine headaches and withdrawal headaches).
Anyone else at home with the same symptoms? Suggests infective cause or environmental exposure such as carbon monoxide poisoning.
Author and Editor – Dr James Mackintosh
Last updated 02/01/24
