History of Headache

History

History of Headache

The history is a crucial step in diagnosis of headaches (Table 1.1). A separate history is required for each type of headache reported, in particular noting the course and duration of each. The International Headache Society has developed classification and diagnostic criteria for the majority of primary and secondary headaches (Box 1.1). Although this is primarily a research tool, standardized diagnostic criteria have helped to ascertain headache prevalence, which is useful for understanding the likelihood of any headache presenting in clinical practice (Tables 1.2 and 1.3).

A headache history requires time. In the emergency setting particularly, there may not be enough time to take a full history. The first task is to exclude a condition requiring more urgent intervention by identifying any warning features in the history (Box 1.2).

Box 1.1 The International Classification of Headache Disorders (2nd edition)

Primary headache                  1. Migraine, including:

                                                     • Migraine without aura

                                                     • Migraine with aura

                                                     • Childhood periodic syndromes that are commonly precursors of migraine

                                                     • Cyclical vomiting

                                                     • Abdominal migraine

                                                     • Benign paroxysmal vertigo of childhood

                                                  2. Tension-type headache, including:

                                                     • Infrequent episodic tension-type headache

                                                     • Frequent episodic tension-type headache

                                                     • Chronic tension-type headache

                                                  3. Cluster headache and other trigeminal autonomic cephalalgias, including:

                                                     • Cluster headache

                                                     • Paroxysmal hemicrania

                                                     • Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

                                                  4. Other primary headaches, including:

                                                     • Primary cough headache

                                                     • Primary exertional headache

                                                     • Primary headache associated with sexual activity

                                                     • Primary thunderclap headache

Secondary headache

                                                  5. Headache attributed to head and/or neck trauma, including:

                                                     • Chronic post-traumatic headache

                                                  6. Headache attributed to cranial or cervical vascular disorder, including:

                                                     • Headache attributed to subarachnoid hemorrhage

                                                     • Headache attributed to giant cell arthritis

                                                  7. Headache attributed to non-vascular intracranial disorder, including:

                                                     • Headache attributed to idiopathic intracranial hypertension

                                                     • Headache attributed to low cerebrospinal fl uid pressure

                                                     • Headache attributed to non-infectious infl ammatory disease

                                                     • Headache attributed to intracranial neoplasm

                                                  8. Headache attributed to a substance or its withdrawal, including:

                                                     • Carbon monoxide-induced headache

                                                     • Alcohol-induced headache

                                                     • Medication-overuse headache

                                                     • Triptan-overuse headache

                                                     • Analgesic-overuse headache

                                                  9. Headache attributed to infection, including:

                                                    • Headache attributed to intracranial infection

                                                10. Headache attributed to disorder of homoeostasis

                                                11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose,  sinuses, teeth, mouth or other facial or cranial structures, including:

                                                   • Cervicogenic headache

                                                   • Headache attributed to acute glaucoma

                                                12. Headache attributed to psychiatric disorder

Neuralgias and other            13. Cranial neuralgias and central causes of facial pain including:

Headaches                                 • Trigeminal neuralgia

                                                14. Other headache, cranial neuralgia, central or primary facial pain

Appendix (unvalidated           Including:

research criteria)                       • Pure menstrual migraine without aura

                                                    • Menstrually-related migraine without aura

                                                    • Benign paroxysmal torticollis

                                                    • Headache attributed to major depressive disorder

New or recently changed headache calls for especially careful assessment. New headache in any patient over 50 years of age should raise the suspicion of giant cell arthritis. Headache is likely to be persistent when present, often worse at night and may be very severe. Jaw claudicating is so suggestive that its presence confirms the diagnosis until proved otherwise. In the absence of ‘red flags’, strictly unilateral headaches may suggest a common headache, such as migraine (Chapter 2) or one of the more rare trigeminal autonomic cephalalgias.

An uncommon but avoidable cause of non-specific c headache in elderly patients is carbon monoxide poisoning. This is caused by using gas heaters, which may be faulty, without adequate ventilation. The symptoms of sub-acute carbon monoxide poisoning include throbbing headache, nausea, vomiting, giddiness and fatigue.

The major fear among patients and healthcare professionals is that a brain tumor is the cause of the headache. In practice, intracranial lesions (tumors, subarachnoid hemorrhage, meningitis) give rise to histories that should bring them to mind. It is rare for brain tumors and other serious conditions to present as isolated headache (Table 1.4). Epilepsy is a cardinal symptom of intracerebral space-occupying lesions, and loss of consciousness should be viewed very seriously. Problems are more likely to occur with slow-growing tumors, especially those in neurologically ‘silent’ areas of the frontal lobes. Subtle personality change may result in treatment for depression, with headache attributed to it. Heightened suspicion is appropriate in patients who develop new.

Table 1.2 Lifetime prevalence of primary headaches

Type of headache                                Prevalence % (95% CI)

Migraine without aura                                     9 (7–11)

Migraine with aura                                          6 (5–8)

Episodic tension-type headache                    66 (62–69)

Chronic tension-type headache                     3 (2–5)

Cluster headache                                           0.1 (0–1)

 

Table 1.3 Lifetime prevalence of secondary headaches

Type of headache                                              Prevalence % (95% CI)

Head trauma                                                            4 (2–5)

Vascular disorders                                                   1 (0–2)

Non-vascular cranial disorders                                0.5 (0–1)

Substances or their withdrawal (excluding              3 (2–4)

hangover)

– hangover                                                              72 (68–75)

Non-cephalic infection                                             63 (59–66)

Metabolic disorder                                                   22 (19–25)

Disorders of the cranium, neck, eyes                      0.5–3 (0–4)

– sinuses                                                                15 (12–17)

Cranial neuralgias                                                   0.5 (0–1)

Table 1.4 Secondary causes of headache identifi ed in the year after presentation in primary care of a

primary headache or new undifferentiated headache

Subsequent secondary                                                 Headache diagnosis at presentation n (%)

diagnosis

                                                                                         New undifferentiated                       Primary headache

                                                                                          headache n = 63 921                       n = 21 758

Subarachnoid haemorrhage                                                     87 (0.14)                                           5 (0.02)

Malignant brain tumour                                                             97 (0.15)                                         10 (0.045)

Benign space-occupying lesion                                                30 (0.05)                                           2 (0.009)

Temporal arteritis                                                                    421 (0.66)                                         40 (0.18)

Stroke                                                                                      678 (1.06)                                         97 (0.45)

Transient ischaemic attack                                                      273 (0.43)                                         54 (0.25)

 

Box 1.2 Warning features in the history warranting investigation

• Acute thunderclap headache (intense headache with abrupt or ‘explosive’ onset)

• Headache with atypical aura (duration >1 hour, or including motor weakness)

• New onset headache in a patient younger than 10 years or older than 50 years

• Progressive headache, worsening over weeks or longer

• Fever

• Symptoms of raised intracranial pressure:

              drowsiness

              postural-related headache

              vomiting

• New onset seizures

• History of cancer or HIV infection

• Cognitive or personality changes

• Progressive neurological deficit:

             progressive weakness

          sensory loss

            dysphasia

            ataxia

An approach to the headache history

An approach to the headache history

Table 1.1 An approach to the headache history

1. How many different headache types does the patient experience?

Separate histories are necessary for each. It is reasonable to concentrate on the most bothersome to the patient but others should always attract some

enquiry in case they are clinically important.

2. Time questions              a) Why consulting now?

                                        b) How recent in onset?

                                       c) How frequent and what temporal pattern (especially  distinguishing between episodic and daily or unremitting)?

                                        d) How long lasting?

3. Character questions             a) Intensity of pain?

                                              b) Nature and quality of pain?

                                              c) Site and spread of pain?

                                              d) Associated symptoms?

4. Cause questions                  a) Predisposing and/or trigger factors?

                                              b) Aggravating and/or relieving factors?

                                              c) Family history of similar headache?

5. Response to headache questions

                                               a) What does the patient do during the headache?

                                               b) How much is activity (function) limited or prevented?

                                               c) What medication has been and is used, and in what manner?

6. State of health between attacks

                                               a) Completely well, or residual or persisting symptoms?

                                               b) Concerns, anxieties, fears about recurrent attacks and/or their cause?

Introduction

Nearly everyone will experience headaches at some time in their lives. Most headaches are trivial, with an obvious cause and minimal associated disability. However, some headaches are sufficiently troublesome that the person seeks medical help. Headache accounts for 4.4% of consultations in primary care (6.4% females and 2.5% males). Unless a correct diagnosis is made, it is not possible to provide the most effective treatment. For most medical ailments the suspected diagnosis can be confirmed with tests, but no diagnostic test can confirm the most common headaches, such as migraine or tension-type headache. This means that unless the headache is obvious, diagnosis is largely based on the history. In addition, the examination of people with primary headaches is essentially normal. Consequently, the diagnosis is not always easy, particularly if several headaches coexist, confusing both patient and doctor. In a study of patients with a diagnosis of migraine who were referred to a specialist migraine clinic, nearly one third had a headache additional to migraine. Failure to recognize and manage the additional headache was the most common cause of treatment failure.

It is not always possible to confirm the diagnosis at the first visit. A structured history, followed by a relevant examination, can identify patients who need immediate investigations or referral from the non-urgent cases. Management and follow-up will depend on whether the diagnosis is confidently ascertained or is uncertain.

OVERVIEW

OVERVIEW of Headache Pain

OVERVIEW

• Most headaches can be managed in primary care

• The history is a crucial step in the correct diagnosis

• Funduscopy is mandatory for anyone presenting with headache

• Diary cards aid diagnosis and management

• The presence of warning symptoms in the history and/or

physical signs on examination warrant investigation and may

indicate appropriate specialist referral