Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep?); the presence of associated neurologic symptoms, nausea, jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise) and alleviating factors (rest, medicines); past history of headache; family history of migraines.
Key Physical Exam: Vital signs; inspection and palpation of the entire head; ENT inspection; complete neurologic exam, including funduscopic exam
Red Flags: SNOOP4 – Systemic signs or symptoms (fever, myalgia, weight loss), Neurologic symptoms, older age (onset > 50), Onset (thunderclap headache onset), Papilledema, Positional, Precip by Valsalva or exertion, Progressive headache or substantial pattern change
Headache
.headachequestions
- “Do you get headaches?”
- “Tell me about your ”
- “Tell me what happens before/during/after your ”
- “When do your headaches start?”
- “How often do you get them?”
- “When your headache starts, how long does it last?”
- “Can you show me exactly where you feel the headache?”
- “What causes the headache to start?”
- “Do you have headaches at certain times of the day?”
- “Do your headaches wake you up at night?”
- “What makes the headache worse?”
- “What makes it better?”
- “Can you describe the headache for me, please? Is it sharp, dull, pulsating, pounding, or pressure-like?”
- “Do you notice any change in your vision before/during/after the headaches?”
- “Do you notice any numbness or weakness before/during/after the headaches?”
- “Do you feel nauseated? Do you vomit?”
- “Do you notice any fever or stiff neck with your headaches?”
“PIN” the migraine diagnosis
- During the last three months, have you had the following with your headaches? 2/3 Yes = migraine (93% predictive in primary care setting)
- Photophopia – light bothered you more than when you don’t have headaches
- Impairment – headaches limit the ability to work, study or do what you need to do
- Nausea – felt nauseated or sick to the stomach