Approach To Patients Presenting With Headache

Headache is one of the common presenting complaints in a physicians office. It is important to identify which headaches are benign, needing no intervention and which requires action. Following questions needs to be asked in history:

Clinical History

1. Does the patient have more than one type of headache?

2. Time:When did the headache start? New or recently changed headache calls for especially careful assessment. How often do they happen? Do they have any patteren( e.g constant,episodic,daily). How long do they last? Why is the patient coming to the doctor now?

3. Character: Nature and quality, site and spread of the pain. Associated symptoms e.g nausea/vomiting, visual disturbance, photophobia, neurological symptoms.

4. Cause: Ask about predisposing and /or trigger factors; aggrravating snd /or relieving factors; family history of similar headaches.

5. Response:Details of medication used (type, dose, frequency, timing). What does the pateint do? e.g can the patient continue work?

6. Health between attacks: Do the headaches go completely or does the patient feel unwell between attacks?

7. Anxieties and concerns of the patient

Physical ExaminationIn acute severe headache, examine for purpuric skin rash. In all cases check BP, brief neurological examination including fundi, visual acuity and gait, palpation of temporal regions/ sinuses for tenderness and examination of neck. In young children measure head circumference and plot on centile chart.

Red Flags To Take Immediate Action

• New unexpected headache
• Thunderclap headache
• Aura for first time and using combined oral contraceptives
• New onset age > 50 yrs or < 10 yrs
• New onset in a patient with a history of HIV or cancer
• Headache with atypical aura ( > 1 hr with or witput motor weakness)
• Progressive headache worsening over weeks
• Associated postural change