HISTORY TAKING AND

HEADACHE CLASSIFICATION

DR GANESHGOUDA MAJIGOUDRA
CONSULTANT NEUROLOGIST
NANJAPPA HOSPITALS DAVANAGERE
ganeshgoudam4@gmail.com
9380906082
 EPIDEMIOLOGY

 >12 million OPD visits.

 30 % have had a migraine in the past year.
 1.7-4 have had a headache at least 15 days or more each month.
 Severe headache/migraine reported in 1 out of 6 Indians (9.7% males, 20.7% females)
 Fifth leading cause of ER visits
 Third highest cause of nationwide of years lost to disability

Primary headache disorders are the majority of headache patients 10%- secondary headaches
 HISTORY TAKING– AN ART

 Headache patients are in pain.

 Often depressed and frustrated.

When you evaluate such a patient, you therefore need to first establish a rapport and
then ask the right questions based on the right suspicions.

“Patients respond to physicians who respond”.

I C H D 3 C L A S S I F I C AT I O N O F H E A D A C H E :
 HISTORY TAKING– AN ART

 Allowed them to speak first

 The spouse and relatives can pitch in later
 It is thought that children are not good historians, but all children above the age of 5 years,
in our experience, can give their own history.
 In multiple chronic pain ask patient to rank the pains in order of impairment.

“Listen to the Patient, quite often he is telling you the Diagnosis!”

 RED FLAGS

Important to keep in mind the “red flags”.

Any new onset headache or anything that is atypical for a particular type of primary
headache should  presence of a secondary headache and warrant imaging.

The clinician should therefore be alert to the overlapping features of primary and secondary
headaches and be vigilant about investigating for red flag features and assessing the temporal
profile (sudden onset of a single headache or loss of pain-free periods between recurrent
headaches) regardless of the clinical “phenotype” of the headache.
RED FLAGS IN THE EVALUATION OF ACUTE HEADACHE

Red flag Possible diagnosis

Older than 50 years Mass lesion, temporal arteritis

Rapid onset with strenuous exercise Carotid artery dissection, ICH

Sudden onset thunderclap headache Bleeding into a mass or AVM, mass lesion , SAH.

Systemic illness with headache(fever, rash) Arteritis, collagen vascular disease, encephalitis,
meningitis

Worsening pattern History of medication overuse, mass lesion and

SDH
RED FLAG POSSIBLE DIAGNOSIS

First or worst headache SAH, RCVS, ICH, Rarely infections

Focal neurological signs ICH, ICSOL, AVM, CVT, RCVS, Dissection

Headache triggered by cough/ exertion/ sexual intercourse SAH, Dissection, ACM(chiary), ICSOL

Headache with change in personality, mental status and CNS infection, ICH, ICSOL
consciousness

Neck stiffness Meningitis, SAH

New onset of severe headache in pregnancy and postpartum Cortical vein / sinus thrombosis, PRESS , carotid artery
dissection, pituitary apoplexy.
• SNOOP4 (“snoop for” red flags)
 SINCE HOW LONG HAVE YOU BEEN HAVING HEADACHES?

 New- onset headaches  Warning bell.

 Acute onset, severe, first and worst headache IS SINISTER.

Sub‑arachnoid hemorrhage, vascular dissection, cerebral venous thrombosis, reversible cerebral
vasoconstriction syndrome, acute hypertensive crisis.
Rarely pituitary apoplexy, colloid cyst, sphenoid sinusitis or spontaneous intracranial hypotension
may present with acute onset headache.
 LOCATION AND PATTERN

 Hemi cranial, Holocranial.

 Migraine headache often alternate sides but can rarely remain side‑locked.
 Side‑locked headaches warrant investigation to rule out an underlying structural cause
 Neck, shoulder or arm pain  Possible cervicogenic headache, although 75% of migraine
patients can have associated neck pain.
 Although typically migraine pain occurs in the V1 territory, it may involve the V2 or V3
distribution, and hence may mimic dental pain.
 Dental interventions may also initiate migraine pain.
 L O C AT I O N A N D PAT T E R N

 Supratentorial structures are innervated by the ophthalmic division of the fifth cranial nerve and
the posterior fossa structures are supplied by C2 and C3..

 Therefore, pain from the upper cervical spine or posterior fossa can be referred anteriorly to the
front of the head.

 Epicranial headaches ( due to irritation of the sensory branches of scalp nerves)

-Primary stabbing headache , Nummular headache
 LOCATION AND PATTERN

 Head pain that spreads into the lower neck (occipital nuchal headache) and
between shoulders may indicate meningeal irritation due to either infection or
subarachnoid blood, its not typical of a benign process.

 Headache from acute angle closure glaucoma Around the eye.

 ANGINAL PAINS REFERRED TO HEAD

 Jaw tip of nose, brow, bregma,occiput palate tip of tongue mastoid upper gums
and teeth which worsens on exertion.
 Extremities, shoulders
 Rarely below umbilicus
 Usually associated with chest discomfort
 In 27% cases of cardiac cephalgia , headache is only manifestation.
 COAT HANGERS HEADACHE

 Patient feels pain in the neck and shoulders in a coat hanger pattern.

 It is due to postural hypotension

 Hence it is important to look for any postural fall of BP in patients with such a complaint.

 Other- Facial pain has many underlying causes, of which trigeminal neuralgia is the most
common, Facial pain has many trigger.
 HOW OFTEN DOES THE HEAD PAIN?

 How often

 Any diurnal /seasonal variation-

 Nocturnal headache--- increased ICT, hypnic headaches, cluster headache

 Early morning awakening headache- increased ICT, hypertensive encephalopathy, OSA.

 Seasonal headache Cluster headache

 DuraHOW OFTEN DOES THE HEAD PAIN? Of The Attack

• An arbitrary duration of 4 hours is considered as the cut‑off between short‑lasting and long ‑lasting
headache.
• The trigemino‑autonomic cephalgias (TACs) /chronic paroxysmal hemicrania (CPH) are 
short‑lasting headaches <4 hours.
• Primary stabbing headaches  last from 10 secs to a minute.
• Trigeminal neuralgia attacks /SUNCT  are of very brief duration, usually a few seconds.
• Migraine headaches on the other hand are of longer duration and last anywhere from 4 to 72 h.
• >72 hours- status migranosus
 H HO W OFT E N DOE S T H E HE AD PA I N? Se v e r e I s T h e Pa i n

 Although not always a useful pointer, most headaches that are pulsatile or throbbing or hammering in
nature are usually due to migraine.

 The other strikingly different short‑lasting pains are the ice pick pains.

 Tension‑type headache is a dull featureless pain with no accompaniments.

 Ask if the headache builds up gradually as with migraine or does it peak rapidly as with the TACs.
 TRIGGERS

 Lifestyle

 Lack of sleep

 Irregular work schedule

 Foods – alcohol, chocolate, cheese etc

 Fragrances (perfumes, paint)

 weather
 ARE THERE ANY ACCOMPANIMENTS TO THE HEAD PAIN?

 Vomiting

 Tinnitus / vertigo

 Cervical and cranial muscle tenderness

 Aura

 Autonomic feature

 Horners syndrome/ adie type pupil/ VISUAL LOSS/TOV’s.

 ARE THERE ANY ACCOMPANIMENTS TO THE HEAD PAIN?

 Neurological deficits HaNDL / Radiculopathies

 Pulsating, throbbing temporal vessels are seen with migraine.

 A tender painful superficial temporal artery can occur with giant cell arteritis.
 Syncope

 Irritability and confusion suggest migraine and restlessness or pacing up and down is more with cluster

 Personality alterations.

 Disinhibition/ impulsivity/ blunt affect/ lack of awareness.

 AUR A

Visual auras are the most common

-Bright zig zag lines
-Visual noise/snow
-Palinopsia/ telopsia
-Diplopia
-Inverted vision

(OCCIPITAL LOBE AND ITS CONNECTION)

Objects may appear closer (pelopsia) or farther away

(teleopsia) than they actually are. Changes in both size
and distance. Objects may appear smaller and seem to
be moving farther away (porropsia)
 AUR A

 They may precede or accompany the headache.

 Auras occur in succession

 Conditions mimicking a migraine aura  strokes, TIAs, seizure disorders, tumors, venous
thrombosis, arteriovenous malformations and carotid dissections.

 The onset, progression and duration of the symptoms help to differentiate between a migraine
aura and a TIA or a seizure.

 Difficulty in making a distinction between these entities occurs when the aura is not followed by
a headache.
 AUR A

• Temporal lobe and its connections:

-Memory disturbances including transient global amnesia
- Visual agnosia and prosopagnosia’
- Dysphasia
-Tinnitus
• Parietal lobe and its connections:
- Paresthesias
- Detachment from the environment
- Visual illusions
- Liliputian hallucinations
-derealization/ depersonalization
- Somatopsychic duality
 AUR A

• Frontal lobe and its connections:

-Executive dysfunction
-Motor dysphasia
Depression and anxiety
Limb weakness

Hypothalamus- Yawning, food cravings, tiredness, mood changes, nausea, attacks may be
linked with hormonal status and the menstrual cycle.
 AUR A

 Brainstem symptoms with probable cortical involvement:

-Vertigo
- Tinnitus: elementary auditory hallucinations
- Ataxia
- Confusion
- Loss of consciousness.
 A gradual onset and progression over a few minutes is characteristic of a migraine aura as
compared with a sudden onset in a TIA or a seizure.
 The classical duration of a migraine aura is 20–30 minutes as compared with a significantly
shorter duration for a seizure and a longer one for a TIA.

 AURA>60 MIN Can lead to migrainous infarction

 PRECIPITATING FACTORS:

 Worsening with Valsalva maneuver/coughing /Laughing or sneezing  posterior fossa or

cranio‑vertebral junctional anomaly such as a Chiari I malformation.

If a secondary cause is ruled out, then one can diagnose a primary cough headache.

Headache worsens on exertion cardiac cephalalgia, phaeochromocytoma, dissection or

primary exertional headache.
 PRECIPITATING FACTORS:

 Spontaneous intracranial hypotension or post lumbar puncture that can worsen with change
to the erect posture.

 Headaches due to raised intracranial pressure can worsen in the supine position.

 Ask for aggravation of the headache with physical activity as in migraine.

 Relieved by lying down SIH

 WORSENED BY lying downICSOL

Other : Cold stimulus headache External pressure headache

 PERSONAL HISTORY &FAMILY HISTORY:

• Consumption of alcohol/smoking can aggravate cluster headache during the active phase.

• Any family history of migraine(70% do have a strong family history)

-Genetic migraines are common
-Familial hemiplegic migraine( Monogenic inheritance)
-CADASIL
 A S K A B O U T T H E I M PA C T O F T H E H E A D A C H E O N T H E PAT I E N T ’ S L I F E S T Y L E ?

• There are instruments such as MIDAS and HIT 6, but these will need monitoring of the headache using
a headache diary.
 ASK ABOUT MEDICATION OVERUSE?

 Caffeine, codeine, analgesics, triptans

 Combined oral contraceptive or phosphodiesterase inhibitors can worsen migraine headache.
 Coronary vasodilators can be associated with severe headaches.
 Many cardiovascular dilatory drugs such as the nitrates, antiarrhythmics, some of the agents for
erectile dysfunction can cause headache as a side‑effect.

 MEDICATION OVERUSE ??? NSAIDS,TRIPTANS

 SPECIAL GROUPS

• History in a child with headache will differ from the elderly patient beyond 50 years who
presents with headache, where different causes will need to be suspected.

ELDERLY AGE GROUP: Stroke ; giant cell arteritis

 HEADACHE I N PREGNANCY/ POSTPARTUM:

-Worsening of migraine in second trimester and postpartum.

Keep in mind!
-Hypertension, PRESS
-CVT
-RCVS
-Pituatory apoplexy
 HEADACHE IN CHILDREN

 Abdominal migraine and cyclic vomiting syndrome seen more often in children.

 Migraine headaches in children are of shorter duration, bifrontal in location, may not have
all the accompaniments as seen in adults and are characteristically relieved by sleep.

 Ask about food habits in children – excessive chocolates, cheese, caffeinated drinks and
monosodium glutamate containing fast food items are well known to worsen headaches.

 Even very young children can present with migraine.

 In children with intracranial tumor, nocturnal and morning headaches are more common, as
are nausea and vomiting.
 HEADACHES ORIGINATING IN OVERLAP SPECIALTIES .

 These headaches need to be referred to the right specialists.

 When you suspect a sinus infection, ask for history of purulent discharge, fever and tenderness over
the sinuses.
 Ophthalmic conditions can be present with headache.
 Subacute angle closure glaucoma is often deceptive and one has to suspect the entity in the right
setting and be alert on examination and refer appropriately.
 Sphenoid sinusitis can present with vertex headache.
 All ocular causes of headache are associated with changes in the external appearance of the eye.
 HEADACHES ORIGINATING IN OVERLAP SPECIALTIES .

 Headache linked to sinusitis

• Characterized by facial pain, pressure, congestion and fullness, nasal discharge, nasal obstruction,
purulence, hyposmia/ anosmia, fever.
• The headaches can be worse on movement, or coughing.
• There may be periorbital pain, and more than 50% patients have fever.
• These features, along with presence of a continuous increasing headache, trigeminal distribution pain,
photophobia, and eye tearing may be a clue .
WhatsAp Video 2023-08-01 at 1.31.31 PM.mp4 WhatsAp Video 2023-08-01 at 1.31.36 PM.mp4
 THANK YOU.
ganeshgoudam4@gmail.com

9380906082