Useful Selected Questions to Ask/Facts to Establish?

• History of the presenting complaint: Start with an open question, for example ‘tell me about your headache,’ and allow the patient to speak freely until they stop. Follow with targeted questions.
  
• Number of types of headache experienced by the patient: Ask directly about the number of different types of headache. Typically ranges from one to several. Understanding, for example, that a patient is suffering frequent tension-type headaches with intermittent migraine-type headaches is important as not all recurrent headaches in a single patient will have the same cause.

Having established the number of types of headache, the following questions can be asked for each subtype:

• Duration: Establish the duration of headache (e.g. a hyperacute onset of headache raising the alarm for a possible vascular aetiology, for example subarachnoid haemorrhage (SAH)) with an accurate and prompt diagnosis being life saving; headaches for the first time and progressing over days or weeks may be due to infective causes (meningitis/encephalitis) or inflammatory (giant cell arteritis) and finally headaches going back many years are typically benign and primary in origin.
  
• Establish whether continuous or episodic.
  
• If episodic, establish the frequency, periodicity and duration of the episodes.
  
• If continuous, establish whether constant or waxing and waning in severity and, if waxing and waning, when these changes occur, for how long they last and the exacerbating and relieving factors.
  
• If episodic, in which part of the head does the pain start? Nature of the pain, i.e. throbbing, pulsatile or stabbing? Evolution of the pain, i.e. does it remain localised to one area, spread to involve one half of the head or become generalised?
  
• Is the headache feature-full or featureless? (Migraine-type headaches, for example, are feature-full with associated nausea, vomiting and photophobia whereas tension-type headaches are usually featureless with headache and possibly associated posterior neck ache being the only symptoms).
  
• Symptoms that precede headache onset [(e.g. visual disturbance including flashing lights (tycopsia), zigzag lines, fortification spectra and spreading haemianopia in migraine-type headache)].
  
• If any associated features (e.g. in migraine, nausea, vomiting, photophobia, phonophobia, dizziness, unilateral sensory disturbance including pins and needles).
  
• Time period for the headache to reach its maximum severity (e.g. in SAH, usually over seconds to a minute whereas in migraine, typically many minutes to an hour, except in specific circumstances such as migraine variants including coital cephalalgia or exertional headache).
  
• If any triggers for the headaches (lack of sleep or excessive sleep, alcohol or certain foodstuffs in migraine).
  
• If any exacerbating factors (e.g. a new onset of continuous headache progressively worsening over weeks to months exacerbated by cough or physical strain and worse in the morning may suggest raised intracranial pressure secondary to an intracranial mass; migraine in women during/with menstruation).
  
• If any relieving factors (including both pharmacological and behavioural factors such as lying quietly in a darkened room or sleeping in migraine).
  
• If any pain in the face (e.g. severe unilateral ocular pain occurring in males in the early hours of the morning suggesting cluster headache or lightening-type unilateral facial pains triggered by chewing or eating suggesting a diagnosis of trigeminal neuralgia).
  
• Ask further specific targeted questions regarding suspected diagnosis (e.g. with cluster headache ask about unilateral eye tearing, unilateral nasal stuffiness or unilateral nose running; with giant cell arteritis ask about unilateral scalp tenderness, pain on hair brushing, jaw claudication and chest pain).
  
• Past medical history (systemic medical conditions can present with headache, for example severe anaemia and metabolic disturbances including alterations in sodium, calcium or glucose).
  
• History of medications (e.g. ones used for headache relief acutely and those taken as prophylactic agents, for example in migraine or cluster headache).
  
• Careful family history (e.g. a strong family history of migraine).