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Headaches

How to (not) take a history

Outline

• Common types of headache

• Patterns and associated features of common headaches

• The best (and worst) questions to ask

• Headaches are common

– 2% of ED attendances

– Most are benign

– Get good at taking a history

Pt 1

• 18 year old female, brought in by parents

• Sore throat for 1 day

• Complains of severe headache, worsening over the course of the day

• Fever

What additional questions should I ask?

• Neck stiffness

• Photophobia

• Confused/drowsy?

• Sinus symptoms

• Unwell contacts

Pt 2

• 55 year old male

• Sudden onset severe headache at 3am

What additional questions should I ask?

• Provoking factors

• Vomiting

• Neck stiffness

• Photophobia

• Had before?

• Drugs?

Pt 3

• 24 year old female

• Headache worsening over course of the day

• No fever

• In a dark room

What additional questions should I ask?

• Photophobia/phonophobia

• Visual symptoms

• Medication

• Had before?

• Relieving/exacerbating factors

Pt 4

• 35 year old male

• Headache for several weeks, not responding to analgesia

What additional questions should I ask?

• Medications

• Relationship to time of day?

• Sleeping?

• Relieving/exacerbating factors

Pt 5

• 24 year old female

• overweight

• Headache for several weeks, worsening, waking from sleep

What additional questions should I ask?

• Relationship with time of day

• Posture?

• Vomiting?

• Visual disturbance

How to take a headache history

How to take a headache history

How to diagnose headaches

Its all about timing

• Onset

• Pattern

• Associated features

Onset Seconds Minutes-hours Hours- days

SAH Meningitis Raised ICP

Stroke Venous sinus thrombosis Tension headache/chronic daily headache

Pituitary apoplexy Sinusitis Malignant hypertension/PRES

Glaucoma Giant cell arteritis

Migraine SDH

Cluster headache Brain abscess

Optic neuritis

Thunderclap headaches

• A true thunderclap headache has an onset within seconds and reaches maximal intensity within 5 minutes.

• Headaches due to a vascular event always last longer than 1 hour

Pattern Time of day Worse in morning

• Raised ICP Worse in evening • Tension

headache

Continuous • Venous sinus

thrombosis • Brain abscess

Location Unilateral • Cluster headache • Glaucoma

Bilateral • Tension

headache • meningitis

Frontal • Sinusitis

Frequency Recurrent • Cluster headache • Chronic daily

headache • Migraine

Singular • Vascular event • Meningitis • Venous sinus

thrombosis

Associated features Fever Meningitis

Neck stiffness Meningitis, SAH, dissection

Visual aura/disturbance Migraine, glaucoma, giant cell arteritis, optic neuritis

Photophobia Meningitis, migraine

Phonophobia Migraine

Drowsiness/confusion Meningoencephalitis, hypertensive encephalopathy

Focal neurology Stroke, abscess, tumour, dissection, venous sinus thrombosis

Trauma SDH, dissection, SAH

Very high BP Hypertensive encephalopathy, intraparenchymal bleed

Red flags

• Age >50 • Altered level of consciousness • Seizure • True thunderclap headache • Associated with exertion • Don’t usually get headaches • Focal neurology • Immunosuppression • Visual disturbance • Pregnancy/post-partum • Medications (anti coagulants, cocaine) • History of cancer

Taking a history

• What time did the headache start? • What were you doing at the time? • How quickly did the headache come on? • No, HOW quickly? • When was the headache at its worst? • Did the headache wake you up or did you wake up with

a headache? • Has it stopped you from doing things? • Have you had a headache like this before? • Is it the worst headache of your life? • Bending/coughing/sneezing

Learning points

• Be persistent in your history taking

• Make sure you fully understand the nature of the headache

• Learn headache patterns