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Headache: History Taking and Differential Diagnoses

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History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Headache

  • Use SOCRATES to assess pain:
    • Site?
    • Onset?
    • Character?
    • Radiation?
    • Associated symptoms?
      • Photophobia
      • Fever
      • Neck stiffness or pain
      • Scalp tenderness
      • Nausea and vomiting
      • Vision problems – double vision, flashing lights
    • Timing?
      • How long do the headaches last?
      • How long do pain-free periods last?
      • Is it progressive/continuous/intermittent? – suggests elevated intracranial pressure
    • Exacerbating or relieving factors?
    • Severity?
  • What effect is this having on their life?

Red flags

Ask about red-flags:

  • Is this the worst headache they have ever had?
  • Is this different to their usual headaches?
  • Has there been any head trauma?
  • Are there features of meningism:
    • Rash?
    • Fever?
    • Neck stiffness?
    • Sensitive to light/sound?
  • Are there features of temporal arteritis?
    • Jaw cramping?
    • Scalp tenderness?
    • Visual problems?
  • Are there features of acute glaucoma?
    • Vision changes?
    • Red eyes?
    • Halos around lights?
    • Nausea/vomiting?
  • Are there features of a raised intracranial pressure?
    • Is it worse when bending over/coughing?
    • Is it worst in the mornings?
    • Are there changes in consciousness such as drowsiness?
    • Is the headache progressively getting worse?
    • Nausea/vomiting?
  • Are there any constitutional features?
    • Fevers?
    • Unexplained weight loss?
    • Night sweats?
    • Generally feeling unwell?

Neurological systems review

  • Any fits?
  • Any falls?
  • Any blackouts?
  • Any dizziness or is the room spinning?
  • Any numbness, tingling, pain, or weakness?
  • How’s their balance?
  • Any loss of bladder/bowel control?
  • Any changes to hearing?
  • Any vision changes?

Features of differentials

Ask about the following where appropriate:

  • Tension-type headache:
    • Does it feel like a tight band is around their head?
    • Is the pain bilateral or diffuse?
    • Is there any associated stress?
  • Medication overuse headache:
    • Do they have features of a tension-type headache that came on/worsened during analgesia use?
    • Have they used analgesics like opioids for a while?
  • Migraine:
    • Is the pain unilateral and throbbing?
    • Does it last from 4-72 hours?
    • Does it stop them from carrying out their activities? – do they lie in a dark room?
    • Are they sensitive to light?
    • Do they take the combined oral contraceptive pill – contraindicated in migraine with aura
  • Trigeminal neuralgia:
    • Do they get shooting or electric-shock-like pain?
    • Does touching the face/cold air/shaving etc. trigger the pain?
  • Cluster headaches:
    • Do they have dull and painful pain usually around one eye?
    • Do they have episodes of pain that last 15 minutes – 3 hours?
    • Do they have eye watering or rhinorrhoea?
  • Subarachnoid haemorrhage:
    • Is it the worst pain they have ever felt?
    • Did the pain suddenly come on?
    • Do they have features of meningism?
  • Meningitis:
    • Do they have features of meningism?
    • Do they have a fever?
    • Do they have a non-blanching rash? 
  • Temporal arteritis:
  • Raised intracranial pressure:
    • Is it worse when bending over/coughing?
    • Is it worst in the mornings?
    • Are there changes in consciousness such as drowsiness?
    • Is the headache progressively getting worse?
    • Nausea/vomiting?
  • Glaucoma:
    • Vision changes?
    • Red eyes?
    • Halos around lights?
    • Nausea/vomiting?
  • Sinusitis:
    • Do they have facial pain?

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
  • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

Examinations to consider include:

  • A neurological examination:
    • General: may show impaired cognition/consciousness and a reduced Glasgow coma scale
    • Visual fields and pupil responses – may show abnormalities
    • Cranial nerve examination – may show abnormalities
    • Upper and lower limb examinations – may show abnormalities in tone, power, reflexes, sensation, vibration, and/or coordination
    • Kernig’s sign and Brudzinski’s sign may be positive 

Investigations

Investigations are generally indicated if secondary headaches are likely. When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
  • Special tests:
    • Non-contrast CT brain – examples include:
      • If it is ‘the worst headache of their life’ to screen for subarachnoid haemorrhage (SAH)
      • If features suggestive of elevated intracranial pressure (ICP) are present
      • If neurological deficits are present
      • If NICE head injury criteria are met
    • CT cervical spine:
      • If there is a history of trauma, if NICE head injury criteria are met
    • Lumbar puncture – provided elevated ICP is not present examples include:
      • SAH (if NICE criteria are met)
      • Meningitis
      • Encephalitis

Differential Diagnoses

Tension headache

  • A history may reveal:
    • Pain is described as a tight band around the head, not pulsatile, pain not severe 
  • Diagnosis is clinical

Migraine

  • A history may reveal:
    • POUNDing: pulsatile, 4-72 hOurs, Nausea +/- vomiting, Disabling intensity (cannot continue normal activity)
    • Migraine with aura may have visual disturbances (e.g. flashing lights) or focal neurological deficits
  • Diagnosis is clinical

Trigeminal neuralgia

  • A history may reveal:
    • Severe unilateral pain lasting for a few seconds with pain-free periods
    • Pain is electric-shock-like and triggered by light touch, cold temperature etc.
  • Diagnosis is clinical

Medication overuse headache

  • A history may reveal:
    • Pain occurring >15 days in a person with overuse of analgesia
    • Headaches worsen when attempting to stop analgesia
    • The new headache is different to the current type they have
  • Diagnosis is clinical

Cluster headache

  • A history may reveal:
    • Severe unilateral orbital or temporal pain lasting 15 minutes to 3 hours
    • Eye redness, lacrimation, nasal congestion, facial swelling
    • Attacks occur in clusters lasting weeks to months with periods of remission
    • Patient may smoke and/or drink alcohol
  • A physical exam may reveal:
    • Agitation, eye redness, lacrimation, ptosis, miosis, runny nose, facial swelling
  • Diagnosis is clinical

Paroxysmal hemicrania

  • A history may reveal features similar to a cluster headache
    • Severe unilateral orbital or temporal pain lasting 15 minutes to 3 hours
    • Eye redness, lacrimation, nasal congestion, facial swelling
    • Attacks occur in clusters lasting weeks to months with periods of remission
    • Patients may smoke and/or drink alcohol
  • Symptoms resolve with indomethacin

Meningitis

  • A history may reveal:
    • Fever, neck stiffness, headaches, nausea, vomiting, photophobia, skin rashes
  • A physical exam may reveal:
    • Brudzinski’s sign, Kernig’s sign
  • Investigations may reveal:
    • Blood culture – identifies underlying organism
    • Lumbar puncture and CSF analysis (if not contraindicated) – identifies underlying organism

Carbon monoxide poisoning

  • A history may reveal:
    • Classically questions may hint at badly maintained housing (e.g. poor boiler function or furnaces)
    • Other household members may have similar symptoms
    • Pets may be unwell
    • Headaches are an early feature, nausea, vomiting, confusion, and weakness follow
  • A physical exam may reveal:
    • Tachypnoea, poor coordination, reduced consciousness
  • Investigations may reveal:
    • Oxygen saturation – may be normal
    • Arterial blood gases – carboxyhaemoglobin:
      • 3% or more in people who do not smoke
      • 10% in people who smoke

Acute sinusitis

  • A history may reveal:
    • Nasal congestion, nasal discharge, post-nasal drip, fever
    • Frontal headache that is worse when bending forwards
  • A physical exam may reveal:
    • Reproducible sinus tenderness when palpating the frontal and maxillary sinuses
  • Diagnosis is clinical

Subarachnoid haemorrhage (SAH)

  • A history may reveal:
    • Sudden severe ‘thunderclap’ headache, may have similar ‘sentinel’ headaches preceding current headache
    • Pain usually reaches maximal intensity within 1-5 minutes
    • Photophobia and neck stiffness may be present
  • A physical exam may reveal:
    • Neck stiffness
  • Investigations may reveal:
    • CT head without contrast:
      • If within 6 hours of symptoms and normal – consider alternate diagnosis
      • If after 6 hours of symptoms and normal – perform lumbar puncture within 12 hours
    • Once SAH confirmed (either by CT or lumbar puncture) – refer to neurosurgery

Stroke

  • A history may reveal:
    • Acute focal neurological deficits are present
    • Headaches are generally rare in ischaemic stroke
  • A physical exam may reveal:
    • Focal neurological deficits
  • Investigations may reveal:
    • CT brain without contrast – may identify haemorrhagic stroke or show hypoattenuation in an ischaemic stroke

Venous sinus thrombosis

  • A history may reveal:
    • Progressive headache, may be sudden
    • Nausea, vomiting, seizures
    • Any cause of a hypercoagulable state (including pregnancy and immediately postpartum) 
  • A physical exam may reveal:
    • Papilloedema, visual field abnormalities, focal neurological deficits, cranial nerve palsies
  • Investigations may reveal:
    • MRI venography – gold standard

Extradural haemorrhage

  • A history may reveal:
    • Head trauma followed by a loss of consciousness, then regaining consciousness (the lucid interval), then losing it again
    • Vomiting 
  • Investigations may reveal:
    • Non-contrast CT head – biconvex (lentiform) hyperdensity limited by skull suture lines

Subdural haemorrhage

  • A history may reveal:
    • More common in neonates, the elderly, and people with chronic alcohol excess
    • Acute – acute head trauma, headaches, nausea, vomiting, seizures, fluctuating consciousness
    • Chronic – weeks to months of confusion, reduced consciousness, nausea, vomiting, focal neurological deficits, seizures 
  • Investigations may reveal:
    • Non-contrast CT head:
      • Acute – crescenteric hyperdensity not limited by skull suture lines
      • Chronic – crescenteric hypodensity not limited by skull suture lines

Giant cell arteritis

  • A history may reveal:
    • Generally seen in people >50 years and more common in women
    • May have a history of polymyalgia rheumatica – proximal stiffness worse in the morning that improves with exertion, malaise
    • Jaw claudication, pain and tenderness in the scalp or temporal area
    • Painless vision loss
  • A physical exam may reveal:
    • Unilateral blindness, temporal tenderness, fundoscopy may show optic nerve oedema
  • Investigations may reveal:
    • ESR – elevated
    • CRP – may be elevated
    • Temporal artery biopsy – confirms diagnosis 

Acute angle-closure glaucoma

  • A history may reveal:
    • Acute unilateral orbital pain with red eyes
    • Blurred vision, halos around light 
    • Nausea/vomiting may be present
  • A physical exam may reveal:
    • Semi-dilating non-reactive pupil, hazy cornea
    • Raised intraocular pressure
  • Investigations may reveal:
    • Tonometry – increased intraocular pressure
    • Gonioscopy – confirms angle closure

Idiopathic intracranial hypertension

  • A history may reveal:
    • Generally an overweight woman, may be pregnant
    • May be taking the combined oral contraceptive pill, corticosteroids, or tetracycline antibiotics
    • Blurred vision, nausea, headache may vary with posture (e.g. coughing, sneezing, leaning forward), headache may be worse in the morning
  • A physical exam may reveal:
    • Papilloedema, enlarged blind spot, CN VI palsy may be seen
  • Investigations may reveal:
    • CT brain – to screen for masses or structural problems
    • MRI brain – to screen for masses or structural problems
    • Lumbar puncture – increased opening pressure

Brain tumours

  • A history may reveal:
    • Headaches that vary with posture (e.g. coughing, sneezing, straining, leaning forward), nocturnal headaches that prevent sleep or wake the patient up, headaches that are present upon waking
    • Focal neurological deficits, unexplained weight loss
  • A physical exam may reveal:
    • Focal neurological deficits
  • Investigations may reveal:
    • CT brain – may show lesions with or without surrounding oedema
    • MRI brain with/without contrast – may show lesion

Brain abscess

  • A history may reveal:
    • A dull, persisting headache
    • Fever, focal neurological deficits, nausea, seizures
    • The patient may be immunocompromised 
  • A physical exam may reveal:
    • Papilloedema
  • Investigations may reveal:
    • CT brain with contrast – shows rings of enhancement and may have surrounding oedema

Pituitary apoplexy

  • A history may reveal:
    • Sudden onset headache similar to subarachnoid haemorrhage
    • Reduced consciousness, nausea, vomiting, neck stiffness
    • Features of pituitary hormone insufficiency
  • A physical exam may reveal:
    • Visual field defects (classically bitemporal hemianopia), oculomotor nerve palsy, hypotension 
    • Investigations may reveal:
  • MRI brain – diagnostic

Pre-eclampsia/eclampsia

  • A history may reveal:
    • >20 weeks gestation, hypertension, oedema, visual disturbances (e.g. flashing lights)
    • If seizures occur this becomes eclampsia 
  • A physical exam may reveal:
    • Blood pressure >140/90 mmHg, proteinuria may be present on dipstick testing
  • Investigations may reveal:

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