Characterising headache

Characterising your patient’s headaches

In the articles of this chapter we delve deeper into the essential details for mastering the diagnosis of headaches. We’ll walk you through characterszing your patient’s headaches by asking the appropriate questions and taking a great headache history. We’ll then look at using a headache diary to help your patient identify food and non-food triggers of headaches.

Perhaps the most important aspect of headache care is accurately diagnosing your patient’s headache type.

An appropriate diagnosis begins with applying what we know about the patient to a framework for headache classification: The International Headache Society’s International Classification of Headache Disorders Version 3 (ICHD-3), updated in 2018. This document can be accessed online and is used to differentiate primary and secondary headache disorders.

An accurate diagnosis allows you to devise the most effective plan of management for your patient’s condition and presentation. First, you must get your patient to describe, in detail the factors that distinguish their headache by taking a headache history.

There are eight characteristics you need to know in order to accurately classify your patient’s headache:

1. Onset
2. Location
3. Duration
4. Frequency and timing
5. Intensity
6. Pain characteristics
7. Course
8. History

Onset of headache(s)

At what age did the headaches begin? Sometimes when the patient is focused on the current presentation, you might have to dig to find out what the headaches were like at the beginning.

How do the headaches begin? Have the patient describe any factors associated with the onset of the headache. Some activities that might bring on a headache include intercourse, Valsalva maneuver, or bending over.

Location of headache(s)

Where in the head is your pain experienced? Are the headaches frontal or occipital? Or holocranial, or encompassing the whole head?

Is the pain always in the same place or does it move around? Either from headache to headache or during a headache?

Duration headache(s)

How long do your headaches last? This information is important to help distinguish the type of headache. Migraines may last many hours while cluster headaches may be much shorter, usually less than three hours. Some other types of headache, such as ice-pick headaches or short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT), may last only minutes or even seconds

Frequency and timing of headache(s)

How frequently do your headaches occur? Do the headaches occur daily, multiple times daily, or monthly? Cluster headaches may occur many times daily, on a seasonal basis, for weeks at a time. Alternatively, migraine might occur monthly, perhaps in association with menstruation

Intensity of headache(s)

Can you rate the severity of your pain on a scale of one to ten? Have your patient grade the severity of their headaches from one to ten. Use a numeric scale or a visual scale to help with this.

Pain characteristics of headache(s)

What does the pain feel like? It is also important for your patient to describe the quality and character of their headache pain. Is the pain steady or throbbing? Is it a stabbing pain, shock-like or burning?

Course of headache(s)

Did the headache evolve or change? Did it get inexorably worse? Did the pain build over hours or minutes?

History of headache(s)

How long have you been suffering? What made you seek care at this time? It might be interesting for you to explore how long your patient has suffered from headaches, and, what drove them to your care at this time. Headache is often suffered in silence and we tend to minimize its impact on our lives. We say we don’t have time for this. However, headache unchecked can become chronic and worsen over time.

References

• The International Classification of Headache Disorders 3rd edition
• Rizzoli P, Mullally WJ. Headache. Am J Med. 2018 Jan;131(1):17-24.
• Migraine Buddies App

Neurology Library: Headache – History, Examination and Investigation

• Coni R. Characterising headache. LITFL
• Coni R. Headache history. LITFL
• Coni R. The headache diary. LITFL
• Coni R. Headache triggers. LITFL
• Coni R. Physical examination. LITFL
• Coni R. Neurological examination. LITFL
• Coni R. Headache and imaging. LITFL
• Coni R. Headache and laboratory tests. LITFL