The most important part of the headache history is to differentiate between primary headaches and secondary headaches! The fine details of the description of a migraine headache for example has low priority.
Primary headache disorders include migraine headaches with and without aura, trigeminal autonomic cephalgia spectrum headaches including cluster headaches, paroxysmal hemicrania, SUNCT, SUNA, hemicrania continua. Secondary headache disorders are headaches derived from structural or secondary cause in which the differential diagnosis is extensive.
The best way to break secondary headaches is by category:
Vascular (Anuersymal or non-anuerymsal ubarachnoid hemorrhage - SAH, cerebral venous thrombosis, cavernous sinus thrombosis, reversible vasoconstriction syndrome, posterior reversible leukoencephalopathy, extra-cranial or intra-cranial dissection), structural (neoplasm, colloid cyst, Chiari I malformation, arteriovenous malformation), inflammatory or infectious (HIV associated immunocompromise, CNS vasculitis or systemic vasculitis, CNS meningitis, encephalitis), ICP related (intracranial hypotension, intracranial hypertension) or pregnancy related (pre-eclampsia spectrum).
Key elements of the headache description include:
Age of onset
Frequency
Duration
Time of onset
Time of maximum intensity
Characteristics - location, quality and severity
Associated symptoms
Precipitating and alleviating factors
Knowing a basic understanding of the secondary etiologies of headache, we can now apply the questions that we ask to help formulate a differential diagnosis.
1) Age of onset - 50 years old or greater?
This question is obviously important because there is an increased risk of cancer as well as the consideration of giant cell arteritis, which affects medium sized arteries and can cause monocular or binocular blindness if not treated promptly with steroids.
This question is obviously important because there is an increased risk of cancer as well as the consideration of giant cell arteritis, which affects medium sized arteries and can cause monocular or binocular blindness if not treated promptly with steroids.
2) Frequency - increasing frequency?
3) Duration - how long does the headache last? is the duration different from previous or established headaches that you have had?
4) TIME OF ONSET AND TIME OF MAXIMUM INTENSITY- what is the onset of headache? how fast does it reach its maximum intensity?
This is important because a "thunderclap headache" in which you need to immediately consider secondary etiologies of headache such as SAH, sentinel bleed from aneurysm, pituitary apoplexy or reversible cerebrovasconstriction syndrome is defined as a headache that REACHES MAXIMUM INTENSITY WITHIN 60 SECONDS. The initial start of the headache occurs within a few seconds. Patients differ in description, but asking if the patient didn't have a headache one moment and then with a snap of the fingers, the patient had a headache, typically brings out this history.
5) Characteristics - location? quality? severity?
Watch out for the description of a new headache or a headache that has changed in location, quality or severity or a headache that is unilateral, especially in a patient that has established headache history (migraine headaches can be unilateral or bilateral as an example). Beware of the temptation to write off a "new headache" in a patient with established primary headache history.
Ask if the headache wakes the patient at night. This can be classically associated with headaches with elevated ICP due to the relative hypercarbic status of the patient when sleeping. Think neoplasm or space occupying lesion and pseudo tumor cerebri.
Ask if the headache wakes the patient at night. This can be classically associated with headaches with elevated ICP due to the relative hypercarbic status of the patient when sleeping. Think neoplasm or space occupying lesion and pseudo tumor cerebri.
6) Associated symptoms - unilateral motor or sensory symptoms? Diplopia, facial sensory deficits or other cranial nerve signs? Altered level of consciousness? Fever? Neck stiffness? Loss of consciousness? Seizures?
For psuedotumor cerebri if suspected, then ask about transient visual obscurations (ask with neck flexion, do they lose binocular vision briefly?), pusatile tinnitus (ask if the patient hears rhythmic whooshing in their ears) and binocular diplopia.
And of course we cannot forget the patient whom is pregnant in their 3rd trimester with a new onset headache. As clinicians, we can never miss the spectrum of pre-eclampsia or eclampsia! This is a life threatening situation for the fetus and the mother. Always check a patient's blood pressure and do a urine dipstick to evaluate for proteinuria. Only determine if it is a primary headache as a diagnosis of exclusion.
For psuedotumor cerebri if suspected, then ask about transient visual obscurations (ask with neck flexion, do they lose binocular vision briefly?), pusatile tinnitus (ask if the patient hears rhythmic whooshing in their ears) and binocular diplopia.
And of course we cannot forget the patient whom is pregnant in their 3rd trimester with a new onset headache. As clinicians, we can never miss the spectrum of pre-eclampsia or eclampsia! This is a life threatening situation for the fetus and the mother. Always check a patient's blood pressure and do a urine dipstick to evaluate for proteinuria. Only determine if it is a primary headache as a diagnosis of exclusion.
7) Precipitating and allevating factors. Now you have to know what to ask.
Ask if the patient has a headache that changes dramatically with position, in which this easy to ask question can differentiate between intracranial hypotension (worse when standing, improved with supine position) and intracranial hypertension (worse in supine position, improved when standing).
Ask if the headache occurred during or after physical exertion, especially sexual intercourse. Consider SAH, dissection, RCVS, 3rd ventricle colloid cyst if you hear this history.
Ask if the headache is triggered by any Valsalva maneuver including coughing, sneezing or straining, which could indicate posterior fossa mass, Chiari I malformation, intracranial hypotension or presence of an aneurysm.
Ask if the patient has a headache that changes dramatically with position, in which this easy to ask question can differentiate between intracranial hypotension (worse when standing, improved with supine position) and intracranial hypertension (worse in supine position, improved when standing).
Ask if the headache occurred during or after physical exertion, especially sexual intercourse. Consider SAH, dissection, RCVS, 3rd ventricle colloid cyst if you hear this history.
Ask if the headache is triggered by any Valsalva maneuver including coughing, sneezing or straining, which could indicate posterior fossa mass, Chiari I malformation, intracranial hypotension or presence of an aneurysm.
NEUROLOGICAL AND PHYSICAL EXAMINATION:
Of course, we can never discount the importance of a neurological and physical examination. An abnormal neurological examination is tantamount to a secondary cause of headache (with exception of trigeminal autonomic cephalgias, which has an obvious pattern discussed in another lecture). Look in the fundus for papilledema, test for Kernig or Bruzinski's sign with the neurological examination. In the physical examination, palpate the temporal arteries, auscultate the carotid arteries (some neurologists that I used to rotate through in medical school state auscultation of the vertebral arteries are possible by placing the stethoscope in the nape of the neck).
