VIDEO
What do the doctor and specialist nurse need to know and why?
The first step in tackling your headache is making the diagnosis. The challenge is in trying to make the symptoms ‘fit the boxes’ as closely as possible – and, if they don’t fit, deciding which box comes closest.
The questions are ones that I ask the patients I see rather than the questions that you might want to ask me. Every patient I see is different, and trying to understand your headache is never easy. Taking the history is about listening to your story, understanding your experience and distilling your answers in the hope that your headache fits into one of the ‘boxes’ from a diagnostic perspective.
The answer lies in the detail. I can make the diagnosis only if I can collect all the information and the questions that follow are about all that information.
Each and every question is a piece of the jigsaw and each piece has to be as clear and accurate as I can make it before looking for the next piece, and all the pieces have to fit together before a clear and accurate picture can be created. There are times when the edges blur and the pieces don’t quite fit, in which case the boxes overlap just a little and they can’t be completely separated.
Part of the assessment includes knowing something about you, your family, and how you live your life. It is also important to know about what treatments you have tried before, what did and did not work as well as what you are using now and how effective it is.
If you want to get the most out of any consultation about your headache or if you feel that the person you are seeing just doesn’t seem to be asking the right questions. These papers will help you get across all the detail needed to establish the right diagnosis.
What the doctors needs to know and why
How old are you now?
Age is important because certain headaches are associated with particular times of life. People at different ages can have an increased risk of developing medical conditions that may give rise to headache symptoms.
How old were you the very first time you got a headache?
When you had your first-ever headache is important for a variety of reasons. A new headache that occurs for the first time later in life may indicate a serious problem – a ‘red flag’ – but if the headache occurred regularly in your teens or twenties and recurs later in life it is less likely to be serious unless the symptom ‘profile’ has changed dramatically.
A high-impact headache that occurs for the first time in someone over the age of 50 could well be serious. For example, temporal arthritis is a potentially serious headache that tends to occur in later years and is less likely to happen in younger people.
Have the headaches been the same since they first started?
Headaches that follow a similar pattern over time are less likely to have serious implications than ones that rapidly develop new and dramatic symptoms. A rapidly worsening picture over days and weeks has greater potential for having a serious cause than one than that evolves over months and years. Symptoms that always occur on the same side may be more likely to be associated with a potentially serious cause than symptoms that occur on either side.
If the headaches have changed, when did that change happen?
A change in headache symptoms can occur for a variety of reasons, and the timing of that change can be helpful in identifying potential triggers. A change in symptoms or the symptom profile may indicate a potentially more serious cause, and this may need to be investigated.
Has the change been gradual or was there something that could have triggered it?
The symptoms of the migraine can develop and evolve over time. The detail is important in understanding why change occurs and in excluding a potentially serious underlying cause. Life events and having another medical condition (or conditions) may well contribute to a change in the headache profile. The development of symptoms during the headache phase may or may not be serious but needs to be assessed carefully.
If the headaches are different, is it:
a. Where you get the pain?
The site of the headache is an important factor in evaluating the possible diagnosis or trigger. Is it one-sided or are both sides affected? Is the pain in the same place or is it different every time? Does it spread or move, or stay in the same place all the time?
b. What the pain feels like?
Is the pain now throbbing whereas it was a pressure or tightness? Do you have an ache all the time that becomes throbbing every now and again?
The description of the pain is one of the criteria used by the doctor to form a diagnosis.
c. How severe the pain is?
The severity of the pain is a criterion used to differentiate between headache types. Understanding the nature of the pain and how it has changed is important in clarifying the diagnosis and deciding which ‘box’ your headache fits into.
d. How long the headache lasts?
The duration of the headache is a feature vital in separating one type of headache from another. The shift from episodic to daily or near daily headache is a difficult one to manage. The duration of the headache is a feature relevant in planning a treatment strategy.
e. How often you get the headache?
An increase in the frequency of headache symptoms may indicate the development of a medication overuse headache or a chronic tension-type headache. A reduction in the number of headache days may suggest an improvement in the headache. The rate of change is important. An increase over days and weeks rather than months and years is more likely to be associated with a serious than a benign cause.
f. A change in your aura?
Aura symptoms tend to follow a typical pattern and are often described as being stereotypical – repeated each time. A change in the pattern of symptoms does occur but if these are significant or dramatic, a more serious cause should perhaps be ruled out.
The question I have to ask myself is: could this be a stroke or mini-stroke or just part of your migraine?
I have to rule out the serious cause before assuming that it is due to the benign cause.
g. A change in the pattern or sequence of symptoms?
New symptoms need to be set in the context of pre-existing ones as well as expected or acceptable ones. There tends to be a natural evolution with migraine, visual symptoms being the most common aura symptoms, but sensory and speech changes can and do occur. Symptoms triggered by specific activities can be relevant, particularly if they are associated with a rise in intracranial pressure, such as results with coughing, intercourse, or exercise.
Do you get any warning symptoms before the headache starts?
The warning phase may be the premonitory symptoms of mood swings, tiredness, yawning, irritability or food cravings, or an aura, which may have visual or sensory symptoms. Certain foods are often thought to be triggers but are more likely to be part of the premonitory phase in which food cravings form part of the start of the attack.
The food craving leads to the food being eaten with the attack already on its way rather than the food causing the attack. Knowing and understanding your premonitory symptoms or aura symptoms are useful predictors of the attack and allow you to treat it early.
Do you get an aura? If so, what do you see or feel?
An aura affects about in 1 in 10 people with migraine, and is most often visual but can be sensory. The symptoms of your aura are always completely reversible – they develop and go away without any active treatment. If you take the right treatment early enough, you might be able to shorten the length of your aura or even prevent your headache from starting.
Tell me what happens during your aura.
The aura is part of the migraine attack, and can vary from person to person. It may vary from attack to attack or change over time. The details are important, because a change in the symptom profile may indicate a potentially serious underlying cause that must be investigated. It is helpful to make a note of the sequence of events and how long each set lasts, as this aids diagnosis.
a. Do you get your visual symptoms first? How long do they last?
b. Do you get pins and needles or numbness next? How long do they last?
c. Do they start with the visual symptoms or after? If after, how long after?
d. Where do the sensory symptoms start? Hands, feet, or face? Is your speech affected, now or later?
e. What happens next?
f. Do you get double vision? If you do, where do you see the second image? Is one eye or both eyes affected? What do you see during your aura?
Detail is important in assessing the nature of the aura and excluding retinal migraine from a more typical visual aura. The questions that follow allow that assessment to occur. Blurring of the vision is a premonitory symptom rather than an aura symptom.
a. Is it at the top, bottom, side?
b. Does it move left to right, right to left, top to bottom, bottom to top?
c. Is it black and white or colored light?
d. Are both eyes affected or just one eye?
e. If you close your left/right eye, is the vision in the eye that is open normal?
How long does your aura last?
An aura should last no longer than 60 minutes and be completely reversible (i.e. it settles spontaneously and completely too normal). If it lasts longer than this, a potentially serious underlying cause may need to be excluded but a prolonged aura can be benign.
Does your headache start when the aura goes, or before?
In some people the headache may start before the aura settles, or the aura may not start until the headache does and can recur during the headache phase. Awareness of the sequence of events helps the doctor to determine the timing of acute treatment options.
Is there a gap between your aura finishing and your headache starting?
The headache of migraine may follow the aura immediately or within 60 minutes: this is migraine with aura. There are times when the aura is not followed by a headache at all, and is called aura without headache.
Does your headache start at a particular time of day or night? Or can it occur at any time?
The time of day that an attack starts can give clues to potential triggers such as falling blood sugar, hunger, or dehydration. Posture and tiredness are also relevant.
Does your headache wake you up in the middle of the night?
Cluster headache tends to occur at night, as does hypnic headache, but being woken by the headache is a potential ‘red flag’. This is one of the symptoms that need to be set in a context of time and previous symptoms.
Where do you get your headache?
The site or location of the headache is one of the features that form a ‘diagnostic criterion’, allowing one headache diagnosis to be separated from another. The questions that follow allow this to be evaluated in adequate detail.
a. Where does it start?
b. Does it move or spread?
c. Is it one-sided or on both sides?
d. Does it start on both sides and get worse on one side or the other?
What does the headache feel like?
Describing pain can be one of the hardest things for a headache sufferer to do but the doctor cannot diagnose the headache without knowing exactly what it feels like. Different headaches are associated with different types of pain and the following questions can help to clarify the headache character.
a. Sharp or dull?
b. Ache or pressure or tightness?
c. Squeezing or stabbing?
d. Throbbing, pulsating, or pounding?
e. Burning or searing?
How bad is the pain?
The severity of the pain is a useful guide to what the headache might be. Mild or mild to moderate headache tends to be of relatively low impact and is more likely to be a tension-type headache than migraine or cluster headache.
A moderate to severe or severe headache is more likely to be migraine or cluster headache than tension-type headache. Separating severity from what the pain feels like is difficult but crucial in trying to decide which diagnosis to make, and therefore which treatments are likely to be best.
Is the pain constant or does it comes in waves or builds to a peak before subsiding?
Understanding what the pain does when present helps the doctor to understand the underlying cause and, potentially, the diagnosis.
How long does the pain last?
The duration of the headache is another of the factors used to make the diagnosis – short, sharp neuralgic pain, as opposed to episodic migraine headache, compared with more chronic headaches. The following questions aid the process of determining the type of headache.
a. Seconds?
b. Minutes?
c. Hours?
d. Days?
e. Several days?
f. Several weeks?
Once the headache has gone, are you back to normal straight away, or does it take you a while to recover?
A slow recovery adds to the impact of the attack by prolonging the process. Understanding the impact and duration of symptoms aids decision-making for both acute and preventative treatments and for evaluating how effective they are.
How often do you get the headache?
It is important to understand the frequency and periodicity (or pattern) of headache symptoms. Is it neuralgia, or a cluster or a tension-type headache? Is this an episodic or a chronic headache? Knowing the time of day or the day in the week the headache occurs may help in determining the triggers and therefore suggesting management approaches. The following questions aid the assessment process.
a. Does it happen at some part or time of every day?
b. Does it happen all day every day?
c. Does it happen once every week, month, or year?
d. Does it seem to happen seasonally?
e. Does it happen around the time of your period?
f. Does it seem to be on a particular day of the week?
g. Is it always at weekends or the start of a holiday?
How many headache days do you get each week, month or year?
This is one of those fail-safe questions to help determine the frequency issue. The frequency of the headache and the frequency with which an acute treatment is used are important in separating a chronic episodic headache from a more chronic daily headache from a medication overuse headache.
The follow-up question is ‘Do you treat every headache you get?’ A ‘Yes’ to that, on the back of a daily or near-daily headache, suggests the possibility of a medication overuse headache.
Does the headache make you feel nauseated or vomit (feel sick or be sick)?
Nausea and vomiting are symptoms typically associated with migraine, which is an episodic headache. If there is a daily or near daily headache with occasional nausea, this could be a medication overuse headache with breakthrough migraine.
Nausea and vomiting early in the attack will affect how well your acute treatment works and which delivery system is best suited to treating the migraine. Understanding the subtlety of the blend and timing of these symptoms is essential in making the diagnosis and planning management.
a. Do you feel sick every time? Or not?
b. What percentage of episodes do you feel sick?
c. What percentage of episodes do you actually vomit?
d. How soon after the attack starts do you start to feel sick?
e. How soon after the attack starts do you start to vomit?
Are you sensitive to light, sound or smells during an attack?
Sensitivity to light, sound and smell are symptoms typically associated with migraine. The blend and balance of symptoms will vary according to the primary diagnosis and whether or not more than one sort of headache is being experienced.
a. Is this with all your headaches?
b. Or with some of your headaches?
c. Is it during your warning phase or aura?
Do you get any diarrhoea with your headache?
Diarrhoea is not a symptom that is often volunteered but is one that can be experienced. It is important to know about it, as it may affect the choice of medication tried for treating the attack: a suppository becomes somewhat futile and an injection or nasal spray more effective.
Do you feel hungry or lose your appetite with your headache?
Loss of appetite tends to be associated with migraine. Hunger may suggest that the attack is waning and recovery is on its way.
Does anything make your headache worse?
Migraine sufferers choose to keep still, cluster headache sufferers have to pace around. If you have neck or back problems, certain actions or activities may increase muscle spasm and lead to headache symptoms.
a. Coughing, sneezing, bending or exercise?
b. Specific activities or movements – e.g. painting, gardening, ironing, making the bed?
Has anything brought the headache on like a bolt from the blue, like a sledgehammer, and stopped you dead in your tracks?
Movement may well make a headache worse but causing or triggering the headache is a potential ‘red flag’. Is a headache triggered during exercise related to low blood sugar or dehydration or something more serious?
Teasing out these symptoms and what they mean requires patience and perseverance.
a. Coughing, sneezing, or bending?
b. Intercourse?
(i) If during intercourse, is it before, during, or after orgasm?
(ii) Is the headache the same or different from your usual one?
(iii) How long does this headache last?
(iv)Do you need to treat it or does it settle on its own?
c. Exercise?
(i) Is it any type of exercise?
(ii) Is it every time you exercise?
(iii) Do you have to exercise at a particular intensity?
- Is it always after you have been exercising for a particular length of time?
(v) Is the headache the same or different from your usual headache?
(vi) How long does this headache last?
(vii) Do you need to treat it or does it settle on its own?
Have you ever been paralyzed with the headache?
Not in the sense of not wanting to move but being physically unable to move. Paralysis is one thing, and a feeling of heaviness or weakness is another. Paralysis may be due to hemiplegic migraine, a transient ischaemic attack (TIA, a mini-stroke) or a stroke. Progressive symptoms of paralysis may indicate a structural lesion within the brain. Symptoms always occurring on the same side, even if reversible, may be signs of a structural lesion in the brain.
Detailed questioning is the only way to tease out the symptoms and understand the underlying pathology or pathophysiology – the causes and effects of the processes associated with a given condition. The precise details or sequence of events offers clues as to which part of the nervous system may be involved in generating the symptoms being experienced.
a. If you have been paralyzed:
(i) When did you first experience this symptom?
(ii) Was it your face, hand, arm, foot, or leg?
(iii) Was it one side or both sides?
(iv) How long did the symptom last?
(v) Did it happen before the headache or with the headache?
(vi)How often has it happened?
(vii) If it has happened more than once, is it always the same side or does it vary from attack to attack?
(viii) What is the exact sequence of symptoms?
(ix) Does it happen with every headache or just some of them?
(x) Does the symptom settle before the headache does, with the headache or after the headache?
Do you have any pins and needles, tingling, numbness, or other changes in sensation?
These ‘sensory’ symptoms can occur as part of the aura or start during the headache. The symptoms have to be completely reversible, spontaneously, during the course of the attack and should settle before the headache does.
Sensory symptoms may occur as a result of other medical, neurological, or orthopedic conditions; for example, carpal tunnel syndrome or sciatica, or even a brain tumor if it is in the right part of the brain. Teasing out the details is crucial in ruling out a potentially serious or structural cause.
a. When did you first experience this symptom?
b. Exactly what symptoms do you have?
c. Do they affect your face, hand, arm, foot, or leg?
d. Were they on one side or both sides?
e. How long did the symptoms last?
(i) Seconds?
(ii) Minutes?
(iii) Hours?
f. If it has happened more than once, is it always the same side or does it vary from attack to attack?
g. What is the exact sequence of symptoms? How do they develop and evolve?
h. How often do you get these symptoms?
i. Do they happen before the headache or with the headache?
j. Do they happen with every headache or just some of them?
k. Do the symptoms settle before the headache does, with the headache or after the headache?
Is your speech affected?
Speech can be affected not only in migraine but also with a stroke or a transient ischaemic attack (TIA). Speech can be affected in the premonitory, the aura, or the headache phase. Speech can be affected in a variety of ways, so the details need to be recognized, highlighted, and understood.
a. Does this happen during the aura or warning phase?
b. Does it happen with the headache?
c. Is it there all the time or does it come and go?
d. How is your speech affected?
(i) Slurring?
(ii) Jumbling of your words?
(iii) Coming out with the wrong words?
Do you have any dizziness symptoms?
‘Dizziness’ is a very subjective word. To make an accurate diagnosis, the doctor needs an objective, descriptive view, so it is important to describe this symptom clearly. Dizziness is a symptom associated with diseases of the ear, nose and throat (ENT) as well as neurological disease.
a. What do you mean by dizzy:
(i) Spinning?
(ii) Unsteadiness?
(iii) Feeling drunk?
(iv) Feeling light-headed or ‘spaced out’
b. Have you fallen?
c. Do you tend to fall or veer in a particular direction?
What effect does the headache have on you?
Its impact on you is one of the most important distinguishing features of headache symptoms. Migraine makes you stop, cluster headache makes you pace, and different headaches do different things.
a. Do you sit still?
b. Do you lie down?
c. Do you want a quiet place?
d. Do you need a quiet, dark place?
e. Can you carry on as normal?
f. Do you have to pace around?
g. Does moving make the headache worse or better?
Do you eat regularly?
Eating regularly is important and, in the presence of other unavoidable triggers, may be all it takes to keep your threshold up enough to prevent a migraine.
a. Do you have breakfast, lunch and dinner every day?
b. Do you have snacks between meals?
c. Do you have a snack before bedtime?
Are you a food junky or do you have a healthy diet?
The quality of what you eat can be as important as the frequency with which you eat. A healthy diet and a healthy lifestyle can combine to result in a higher migraine threshold, which means potentially fewer migraine attacks.
Do you avoid or exclude any particular foods?
A balanced diet is important to provide the essential food groups as well as vitamins and minerals needed for a healthy body. A healthy body usually means a healthy and happy person, which means fewer headaches and fewer migraines.
Excluding a wide range of foods and food groups tends to lead to a very narrow and restricted diet, lacking the full range of vitamins and minerals needed for a healthy body. A true food trigger is rare and usually self-evident. Food cravings during the premonitory phase do occur and can easily be mistaken for a trigger of the migraine rather than part of the attack process, which has already started when you get your craving.
Do you drink plenty of fluids?
Dehydration can cause headache, as can too much caffeine. It is possible to get a rebound headache from caffeine withdrawal. Artificial sweeteners may contribute to headache symptoms, so what you drink is as important as how much.
a. How many cups of tea or coffee do you drink each day?
b. Do you have caffeinated or decaffeinated hot drinks?
c. Do you drink Coke or Pepsi?
(i) Caffeinated or decaffeinated?
(ii) Low cal or regular?
(iii) How many cans or bottles each day?
d. Do you drink water?
(i) Flavored or not?
(ii) How many cups, glasses, or bottles?
e. Do you drink any other drinks?
f. Do you drink alcohol?
(i) Do you drink wine, beer, or spirits?
(ii) How many units each day, week, or month?
What hobbies or interests do you have?
Having a balance between work, chores, and play is crucial to feeling well and being happy. A happy and contented person will tend to have a higher migraine threshold than one who is too busy and too stressed. Having some time that is devoted to being ‘me’ is important in being and feeling in control.
What things cause you worry, stress, or anxiety?
Stress can be both positive and negative. Recognizing the highs and lows means you can get the balance right and stay in control. Knowing when your limits are being stretched or over-stretched means knowing when to ask for help and actually doing it.
How do you manage your headache?
Headaches are all different, and how we deal with them varies. Knowing what works for you is important; as is finding new things to try that might work better.
What do you take to treat your headache?
There are a range of treatments available to manage the wide variety of headaches. Knowing what to take for what sort of headache is essential, as the wrong treatment can cause more problems than it solves. Treating the headache is not just about treating the pain, but is also about tackling all the other associated symptoms that can be just as disabling.
a. Do you take a simple painkiller?
(i) What do you take?
(ii) How many do you take?
(iii) How often do you take it?
b. Do you take something for the nausea and vomiting?
(i) What do you take?
(ii) Is a single dose enough or do you have to repeat it?
c. Do you take a triptan?
(i) Which one do you take?
(ii) What strength or dose do you take?
d. Do you use a mix of tablets?
e. Do you take a single dose or repeat your dose of medication?
(i) How often do you have to repeat your dose of medication?
When do you take your treatment?
When you take your treatment can be as important as what you take. Timing is everything – too early can be as ineffective as too late.
a. Is it with the aura?
b. With the warning phase?
c. With the start of the headache?
d. After the headache has been present for an hour, a few hours or several hours?
How effective is your treatment?
Everyone has a different goal when it comes to measuring how effective their treatment is. How quickly something works is relative to how long the headache would have lasted without treatment. A sustained response varies as much with early treatment as what drug is used. Drugs used in combination may be a better solution than one on its own.
a. Does it stop the headache from developing?
b. Does it ease the headache?
c. How long does it take to ease the headache?
d. Does it get rid of the headache completely?
e. How long does it take to get rid of the headache?
f. Does the headache come back in the next 24 to 48 hours?
g. Does it get rid of any or all of the other symptoms?
h. Do you get any side effects?
i. If you do get side effects, how bad are they?
j. If your treatment is effective, can you put up with the side effects?
How many days in the week do you take an acute treatment?
This is another question designed to discover the person with medication overuse headache, as they are usually reluctant to admit to exactly how many tablets they take!
Do you take a single dose in the day or more than one?
It is important to know exactly how many doses are needed for effective treatment. The goal is a drug or drug combination that works quickly, relieves all of the symptoms, has few or no side effects, is easy to use, and does not allow the headache to recur.
