Unlocking the Mystery of Outpatient Headaches: Expert Tips for History-Taking

By: Dr. Farhat Naz

Headache Definition, Types, Classification, History, Challanges,Treatment

• Case scenario
• What is headache?
• What are important causes of headache?
• How headaches are broadly classified?
• What is the frequency of primary and secondary headache?
• What are causes of primary headache?
• What are causes of secondary headaches?
• How different headaches are diagnosed?
• Why history taking is important in headache?
• What are steps in history taking in headache?
• What are red flags in history of headache?
• What is thunderclap headache and what are the causes?
• List causes of headaches related to other specialities?
• How headache is treated?

Case History:

John, a 35-year-old man, has been experiencing severe headaches on the right side of his head for the past two months. The pain is excruciating and usually lasts between 30 minutes to three hours. It is accompanied by redness and tearing in his right eye, nasal congestion, and restlessness. John has been experiencing these headaches daily, with up to eight attacks per day. The attacks usually occur at night, waking him up from sleep.

John has tried over-the-counter painkillers like ibuprofen and paracetamol but they do not seem to provide any relief. He has also noticed that lack of sleep and certain foods like chocolate and cheese can trigger the headaches.

Upon examination, John’s doctor suspects that he is suffering from cluster headaches and refers him to a neurologist. The neurologist confirms the diagnosis and prescribes medication to help manage the pain.

John is prescribed oxygen therapy and subcutaneous sumatriptan injections. The oxygen therapy involves inhaling 100% oxygen through a mask for 15 minutes, which helps to alleviate the pain. Sumatriptan injections are used to abort the headaches during an attack.

The neurologist also recommends lifestyle changes to help manage the headaches. John is advised to avoid smoking and foods that trigger the headaches. He is also advised to maintain a regular sleep schedule and avoid any activities that can disrupt his sleep pattern.

Over time, John’s cluster headaches become less frequent and less severe. He continues to take medication and follow the lifestyle changes recommended by his neurologist. John is able to resume his normal activities and no longer experiences the debilitating pain he once did.

Past medical history:

John has no significant medical history and has not been hospitalized before.

He has had occasional migraines in the past but they were not as severe as his current headaches.

Family history:

John’s mother has a history of migraine but no one else in his immediate family has ever experienced cluster headaches.

His father has high blood pressure and his grandfather had a heart attack in his 60s.

Drug History:

John has been taking over-the- counter painkillers like ibuprofen and paracetamol for the past two months to manage his headaches, but they have not provided any significant relief.

Upon diagnosis of cluster headaches, he was prescribed oxygen therapy and subcutaneous sumatriptan injections to help manage the pain.

John reports no known drug allergies or adverse drug reactions.

Personal history:

John is a smoker and has been smoking for the past 10 years.

He is fond of coffee and take frequently to keep his mind fresh while working.

He works as a software engineer and spends most of his day sitting in front of a computer.

John is married and has two children. His wife is a stay-at-home mom and takes care of the children.

Socioeconomic history:

John belongs to the middle class and has a stable job.

He has health insurance through his employer. He lives in Islamabad and owns a home. John’s family has no significant financial burdens.

What is Headache?

Headache is a common symptom experienced by many people at some point in their lives. It is characterized by pain or discomfort in the head, scalp, or neck area, and can vary in intensity, duration, and location. Headaches can be caused by a variety of factors, including tension, stress, dehydration, sinus congestion, eyestrain, illness, injury, or certain medical conditions. They can also be a side effect of medication or a symptom of a more serious underlying health problem.

What are important causes of headache?

There are many different causes of headaches, some of which are more common than others. Here are some of the most important causes of headaches:

1. Tension headaches: These are the most common type of headache and are usually caused by muscle tension in the neck and head.
2. Migraines: These are severe headaches that often cause throbbing pain on one side of the head, and are often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light and sound.
3. Cluster headaches: These are severe headaches that occur in clusters or cycles, usually on one side of the head. They can be very painful and often occur in the middle of the night.
4. Sinus headaches: These are headaches caused by sinusitis, or inflammation of the sinuses. They are often accompanied by facial pain.
5. Rebound headaches: These are headaches that occur as a result of overusing pain medication.
6. Hormonal headaches: These are headaches that occur as a result of hormonal changes in the body, such as during menstruation or menopause.
7. Headaches caused by medical conditions: These include headaches caused by conditions such as high blood pressure, brain tumors, or infections.

How headaches are broadly classified?

Headaches are classified into two main categories:

1. Primary headaches
2. Secondary headaches

Primary headaches are headaches that occur without an underlying medical condition or other identifiable cause. They are typically caused by overactivity or problems with structures in the head that are pain- sensitive, such as blood vessels, muscles, and nerves. Examples of primary headaches include tension headaches, migraines, and cluster headaches.

Secondary headaches, on the other hand, are headaches that are caused by an underlying medical condition or other identifiable cause, such as a head injury, infection, or medication overuse. Examples of secondary headaches include headaches caused by sinusitis, head and neck injuries, brain tumors, and temporal arteritis.

Headaches can also be classified on the basis of their duration and frequency. For example, acute headaches are those that last less than 4 hours, while chronic headaches are those that occur for more than 15 days per month. Some types of headaches, such as migraines and cluster headaches, may occur in cycles or episodes.

It is important to identify the type and cause of a headache in order to determine the appropriate treatment.

What is the frequency of primary and secondary headache?

The frequency of primary and secondary headaches varies depending on the population studied and the specific type of headache being considered.

Primary headaches, which include tension headaches, migraines, and cluster headaches, are the most common type of headache, accounting for up to 90% of all headaches. Tension headaches are the most common type of primary headache, affecting up to 78% of people at some point in their lives, while migraines affect around 15% of the population. Cluster headaches are less common, affecting around 0.1% of the population.

Secondary headaches, which are caused by an underlying medical condition or other identifiable cause, are less common than primary headaches. However, the frequency of secondary headaches also varies depending on the underlying cause. For example, headaches caused by sinusitis are relatively common, affecting up to 12% of the population, while headaches caused by brain tumors are much less common, affecting less than 1% of people with headaches.

It is important to note that these estimates are based on general population studies and may not apply to specific subpopulations or individuals. Additionally, the frequency of headaches may be influenced by various factors such as age, gender, genetics, and lifestyle.

What are causes of primary headache?

Primary headaches are a type of headache that occur without an underlying medical condition or other identifiable cause. They are typically caused by overactivity or problems with structures in the head that are pain-sensitive, such as blood vessels, muscles, and nerves. Causes of primary headaches include

Tension headaches

Migraine headaches

Cluster headaches.

These headaches can be recurrent, and may be triggered by certain factors such as stress, certain foods or drinks, or changes in sleep patterns.

Primary headaches are generally not life-threatening, but can significantly affect quality of life and productivity. Treatment options for primary headaches vary depending on the type and severity of the headache, and may include lifestyle modifications, such as stress management and regular exercise, as well as medications to alleviate pain and prevent future episodes.

What are causes of secondary headaches?

Secondary headaches are caused by an underlying medical condition or other identifiable cause. Here are some of the most common causes of secondary headaches:

1. Head and neck injuries: Traumatic injuries to the head or neck, such as concussions or whiplash, can cause secondary headaches.
2. Sinusitis: Inflammation of the sinuses can cause headaches, particularly around the eyes and forehead.
3. Medication overuse: Overuse of pain medications such as aspirin, ibuprofen, and acetaminophen can cause rebound headaches.
4. Infections: Headaches can be a symptom of infections such as meningitis, encephalitis, and influenza.
5. Brain tumors: Tumors in the brain can cause headaches, particularly if they increase pressure within the skull.
6. Temporal arteritis: This is a condition in which the arteries in the head and neck become inflamed, causing headaches and other symptoms.
7. High blood pressure: Hypertension can cause headaches, particularly in the morning.
8. Dental problems: Dental issues such as temporomandibular joint disorder (TMJ) can cause headaches.
9. Hormonal changes: Hormonal changes, such as those that occur during menstruation or menopause, can cause headaches.
10. Other medical conditions: Other medical conditions that can cause headaches include glaucoma, intracranial hemorrhage, and cervical spine disorders.

How different headaches are diagnosed?

The diagnosis of headaches typically involves a thorough medical history and physical examination, as well as additional tests or procedures as needed. Here are some of the steps involved in the diagnostic process:

1. Medical history: The doctor should ask questions and details about headaches, such as when they started, how often they occur, and what triggers them.
2. Physical examination: It is performed by doctor to look for signs of any underlying medical conditions that may be causing headaches.
3. Imaging tests: Imaging tests such as CT scans or MRI may be ordered to look for abnormalities in the brain that may be causing headaches.
4. Laboratory tests: Blood tests may be ordered to check for conditions such as infections, inflammation, or hormonal imbalances.
5. Headache diary: Keeping a diary of headaches by patient can be helpful in identifying triggers and patterns that may be contributing to headaches.

The diagnosis of headaches can be complex, as there are many different types of headaches and many possible causes. It is important to consult the doctor who is experienced in diagnosing and treating headaches in order to get an accurate diagnosis and appropriate treatment.

Is imaging needed in all headaches?

Imaging is not always needed in all headaches. In fact, most headaches do not require imaging tests such as CT scans or MRI.

Imaging tests may be recommended if there are certain red flags or warning signs present that suggest a more serious underlying condition, such as a brain tumor or aneurysm. These red flags may include:

1. Sudden onset of a severe headache (“thunderclap headache”)
2. Headache that is different from previous headaches
3. Headache that worsens over time
4. Headache that is accompanied by other neurological symptoms, such as weakness, numbness, or difficulty speaking.
5. Headache that is accompanied by fever, stiff neck, or other signs of infection
6. Headache that occurs after a head injury
7. Headache in a person with a history of cancer or immunosuppression.

If none of these red flags are present, imaging tests are generally not needed. Instead, a healthcare provider may recommend lifestyle changes, over-the-counter pain relievers, or prescription medications to manage the headaches.

What investigations are performed in headache?

The investigations that may be performed in the evaluation of headaches depend on the suspected cause of the headache. Here are some of the common investigations that may be performed:

1. Blood tests: Blood tests may be ordered to check for conditions such as infections, inflammation, or hormonal imbalances that may be causing the headaches.
2. Imaging tests: Imaging tests such as CT scans or MRI may be ordered to look for abnormalities in the brain that may be causing the headaches. These tests can also help to rule out serious conditions such as tumors or aneurysms.
3. Lumbar puncture: A lumbar puncture, also known as a spinal tap, may be performed to check for infections or other abnormalities in the cerebrospinal fluid (CSF) surrounding the brain and spinal cord.
4. EEG: An EEG, or electroencephalogram, may be ordered to measure the electrical activity in the brain and identify any abnormal patterns that may be causing the headaches.
5. Sleep studies: Sleep studies may be performed to evaluate for sleep disorders such as sleep apnea, which can cause headaches.
6. Vision tests: Vision tests may be performed to evaluate for eye conditions such as glaucoma, which can cause headaches.

It is important to note that not all of these investigations are necessary for all headaches. The investigations that are performed will depend on the suspected cause of the headache and the presence of any red flags or warning signs.

Why history taking is important in headache?

Obtaining a detailed history is crucial in evaluating patients with headaches, and can provide valuable information for determining the underlying cause and appropriate treatment. Here are some important points to cover in the history of a patient with a headache:

1. Type of headache: Determine the type of headache the patient is experiencing, whether it is a tension-type headache, migraine, cluster headache, or other type of headache.

2. Onset and duration: Ask when the headache started, how long it has been going on, and if there is any pattern to the headaches.
3. Severity: Determine the severity of the headache and how it affects the patient’s daily activities.
4. Location: Determine the location of the headache and if it radiates to other areas.
5. Quality: Ask the patient to describe the quality of the headache, such as a throbbing, pounding, or squeezing sensation.
6. Triggers: Determine if there are any triggers that may be causing the headaches, such as stress, certain foods, or environmental factors.
7. Associated symptoms: Ask about any associated symptoms that may be present, such as nausea, vomiting, photophobia, phonophobia, or aura.
8. Medical history: Obtain a thorough medical history, including any history of head injuries, sinus infections, or other medical conditions that may be contributing to the headaches.
9. Medications: Ask about any medications the patient is taking, as some medications can cause headaches as a side effect.
10. Family history: Determine if there is any family history of migraines or other types of headaches.

By obtaining a thorough history, healthcare providers can gain valuable information to help diagnose and treat headaches appropriately.

What are ‘red flags’ in history of headache?

The following points in history of a patient with headache point towards serious causes and may need further workup:

• First or worst ever headache.
• New onset severe headache
• Onset of new headache after 50 years.
• Change in pattern or intensity of previous headache.
• Onset of headache during exertion, coughing, straining, sneezing, sex related.
• Worsening headache since onset.
• Headache with postural link
• Headache in patients with malignancy, HIV
• Headache with systemic symptoms like fever, vomiting, cough or weight loss.
• Neurological symptoms and signs like altered consciousness, fits, weakness.

What is thunderclap headache and what are the causes?

Thunderclap headache is defined as the headache which reaches its maximum intensity within seconds to minutes of its onset. The rapidity and severity at onset are features of thunderclap headache. The following are important causes of thunderclap headache:

• Subarachnoid hemorrhage
• Sentinel headache
• Cerebral venous thrombosis
• Sudden decrease in intracranial pressure
• Sever hypertension
• Stroke
• Reversible vasoconstriction in brain
• Brain and meninges infection

What is chronic daily headache (CDH) and what are possible causes for it?

Few patients complain of chronic daily headaches. CDH is a term which is defined as the headache which is experienced for more than 15 days a month for more than 3 months. The headache mostly last for less than 4 hours but may last longer than it. The following are possible causes for it:

Headache for less than 4 hours:

• Cluster headache
• Paroxysmal hemicrania
• Trigeminal neuralgia
• Idiopathic stabbing headache
• Cough headache
• Benign exertional headache
• Headache associated with sexual activity

Headache for more than 4 hours:

• Chronic (transformed) migraine
• Chronic tension-type headache
• New daily persistent headache

What clinical examination is performed in headache?

The examination that is performed in a patient with a headache will depend on the suspected cause of the headache. Here are some common examinations that may be performed:

• Neurological examination: A neurological examination may be performed to check for any abnormalities in the nervous system, including the brain, spinal cord, and nerves.
• Eye examination: An eye examination may be performed to evaluate for any eye conditions that may be causing the headaches, such as glaucoma or optic neuritis.
• Blood pressure: A blood pressure check may be performed to rule out high blood pressure as a cause of the headache.
• Head and neck examination: A head and neck examination may be performed to check for any signs of tension in the muscles of the head and neck.
• Sinus examination: A sinus examination may be performed to check for any signs of sinusitis, which can cause headaches.
• Temporomandibular joint (TMJ) examination: A TMJ examination may be performed to check for any abnormalities in the jaw joint that may be causing headaches.

It is important to note that not all of these examinations are necessary for all headaches. The examinations that are performed will depend on the suspected cause of the headache and the presence of any red flags or warning signs.

How headaches are treated?

The treatment for headaches will depend on the underlying cause of the headache. Here are some common treatments for different types of headaches:

• Tension headaches: Tension headaches are often treated with over-the-counter pain relievers such as acetaminophen or ibuprofen. Relaxation techniques, stress management, and physical therapy may also be helpful.
• Migraines: Migraines may be treated with over-the-counter or prescription medications such as triptans or ergotamines. Lifestyle changes such as regular exercise, stress reduction, and avoiding triggers such as certain foods or bright lights may also be helpful.
• Cluster headaches: Cluster headaches may be treated with oxygen therapy, sumatriptan injections, or other prescription medications such as verapamil or lithium.
• Sinus headaches: Sinus headaches may be treated with decongestants, antihistamines, or nasal corticosteroids.
• Headaches due to medication overuse: If headaches are caused by overuse of pain relievers, the treatment may involve gradually reducing the use of these medications under the supervision of a healthcare provider.
• Trigeminal neuralgia: Trigeminal neuralgia may be treated with anticonvulsant medications such as carbamazepine or gabapentin.
• Chronic daily headache: Chronic daily headache may be treated with a combination of medications and lifestyle changes such as regular exercise, stress reduction, and good sleep hygiene.
• In addition to medication and lifestyle changes, other treatments such as physical therapy, cognitive-behavioral therapy, or acupuncture may also be helpful for certain types of headaches.