Headache history Taking | OSCE Guide

Learn a structured headache history for OSCEs, including key questions, red flags, differentials and examination points for PA students.

1. 🧼 Opening the Consultation

  • Wash or sanitise hands
  • Introduce yourself: "Hi, my name is (Name), one of the physician associates"
  • Confirm the patient's full name and date of birth
  • Gain consent: "Would it be okay if I asked you some questions about your headaches?"
  • Establish whether the patient currently has a severe headache or appears acutely unwell

2. ❓ Presenting Complaint

  • Begin openly:
    • "What brought you in today?"
    • "Can you tell me about the headaches you've been experiencing?"
  • Establish whether this is:
    • A first-ever headache
    • A new type of headache
    • A recurrence of a familiar headache
    • A significant change in a longstanding headache pattern
  • If the patient says… You should consider…
    "It feels like a tight band around my head" Tension-type headache
    "It's throbbing and light makes it worse" Migraine
    "It's unbearable around one eye and my eye waters" Cluster headache
    "It came on instantly – the worst headache I've ever had" Thunderclap headache – subarachnoid haemorrhage must be excluded
    "My scalp hurts when I brush my hair" Giant cell arteritis, particularly if aged 50 or over
    "My jaw aches when I'm chewing" Jaw claudication – consider giant cell arteritis
    "The pain shoots across my face when I touch it" Trigeminal neuralgia
    "This headache is completely different from my normal migraines" Consider a secondary headache cause

3. 🩺 History of Presenting Complaint

  • Site: "Where exactly do you feel the headache?"

    Bilateral pressure may suggest tension-type headache. Migraine may be unilateral or bilateral. Severe unilateral orbital or temporal pain may suggest cluster headache.

  • Onset: "When did it start? Did the pain come on suddenly or gradually?"

    A headache reaching maximum intensity within minutes is a red flag and requires assessment for causes such as subarachnoid haemorrhage.

  • Time to maximum intensity: "How quickly did the headache reach its worst?"

    This is particularly important when assessing a possible thunderclap headache.

  • Character: "How would you describe the pain?"
    • Throbbing or pulsating?
    • Pressure or tightening?
    • Sharp or stabbing?
    • Burning?
    • Electric shock-like?
  • Radiation: "Does the pain spread anywhere else, such as your face, jaw or neck?"
  • Duration: "How long does each headache last?"

    Duration is useful diagnostically: migraine typically lasts hours, while cluster attacks are shorter and trigeminal neuralgia causes very brief attacks.

  • Frequency: "How often are you getting the headaches?"
    • How many days each week?
    • How many headache days each month?
    • Are there completely pain-free periods?

    Frequency helps distinguish episodic from chronic headache and should prompt assessment for medication-overuse headache.

  • Progression: "Are the headaches becoming more frequent or more severe?"

    A substantial change in headache characteristics should prompt consideration of a secondary cause.

  • Triggers: "Have you noticed anything that brings the headache on?"
    • Stress
    • Sleep deprivation
    • Missed meals
    • Dehydration
    • Alcohol
    • Menstruation
    • Exercise
    • Coughing or sneezing
    • Sexual activity
    • Bending or straining

    A new headache precipitated by coughing, Valsalva, sneezing or exercise requires further assessment.

  • Posture: "Does sitting, standing or lying down make the headache better or worse?"

    A clearly posture-dependent headache is a red flag for secondary causes and warrants further assessment.

  • Severity: "On a scale of 0 to 10, how severe is the pain?"
  • Effect on activity: "Can you continue your normal activities when you have the headache, or do you need to stop and rest?"

    Migraine commonly limits normal activity. People with cluster headache may instead become restless or agitated during attacks.

4. 👁️ Associated Symptoms

  • Migraine features:
    • Nausea or vomiting
    • Photophobia
    • Phonophobia
    • Worsening with normal physical activity
  • Aura:
    • Visual disturbance
    • Flashing lights or zig-zag lines
    • Sensory symptoms
    • Speech disturbance

    Typical migraine aura develops gradually, is fully reversible and usually occurs before or with the headache. Sudden persistent neurological symptoms should not automatically be attributed to migraine.

  • Eye/autonomic symptoms:
    • Red eye
    • Lacrimation
    • Nasal congestion
    • Runny nose
    • Eyelid swelling
    • Ptosis

    Ipsilateral autonomic symptoms accompanying severe unilateral orbital or temporal pain strongly suggest cluster headache.

  • Neurological symptoms:
    • Weakness
    • Numbness
    • Facial droop
    • Speech disturbance
    • Diplopia
    • Loss of balance or coordination
    • Seizure
    • Confusion
    • Reduced consciousness
  • Infection/meningism:
    • Fever
    • Neck pain or stiffness
    • Photophobia
    • Vomiting
    • Non-blanching rash
    • Altered behaviour or consciousness
  • Giant cell arteritis symptoms:
    • New headache in someone aged 50 or over
    • Scalp tenderness
    • Jaw claudication
    • Visual disturbance or visual loss
    • Symptoms suggestive of polymyalgia rheumatica

5. 🚩 Red Flag Headache Screen

Ask specifically about:
  • Sudden severe headache reaching maximum intensity within minutes
  • New focal neurological symptoms
  • New cognitive dysfunction or personality change
  • Reduced level of consciousness
  • Seizure
  • Worsening headache with fever
  • Neck stiffness
  • Recent head trauma
  • Headache triggered by coughing, sneezing or Valsalva
  • Headache triggered by exercise
  • Headache significantly altered by posture
  • Unexplained vomiting
  • New visual symptoms
  • Scalp tenderness or jaw claudication
  • Immunosuppression, including HIV or immunosuppressive medication
  • Previous malignancy, particularly one with potential to metastasise to the brain
  • Substantial change in an established headache pattern
  • Pregnancy or recent postpartum period where clinically relevant
  • Anticoagulant use or a significant bleeding risk

6. 🧠 Recognising Common Headache Patterns

If the patient describes… You should consider…
Bilateral pressing or tightening pain, mild-moderate intensity, not significantly worsened by routine activity Tension-type headache
Pulsating moderate-severe headache, aggravated by normal activity, with nausea/vomiting and/or photophobia and phonophobia Migraine
Severe or very severe unilateral orbital, supraorbital or temporal pain with ipsilateral tearing, red eye, nasal symptoms or restlessness Cluster headache
Brief recurrent electric shock-like facial pain triggered by touching the face, chewing, talking or brushing teeth Trigeminal neuralgia
New headache in a person aged 50 or over with scalp tenderness, jaw claudication or visual symptoms Giant cell arteritis
Sudden severe headache reaching maximum intensity within minutes, particularly with neck stiffness, vomiting, photophobia or neurological symptoms Subarachnoid haemorrhage
Headache with fever, neck stiffness, photophobia, altered consciousness or non-blanching rash Meningitis / CNS infection
Progressive headache with vomiting, neurological deficit, seizure, cognitive change or features suggesting raised intracranial pressure Intracranial pathology / raised intracranial pressure
Increasing headache frequency while using acute headache medication frequently Medication-overuse headache

7. 📋 Past Medical History

  • Previous migraine or recurrent headaches
  • Previous similar episodes
  • Hypertension
  • Previous stroke or TIA
  • Epilepsy
  • Recent infection
  • Previous meningitis or CNS infection
  • Head or neck trauma
  • Malignancy
  • Immunosuppression
  • Giant cell arteritis or polymyalgia rheumatica
  • Glaucoma

8. 💊 Drug History & Allergies

  • "What medications are you currently taking, including anything you've bought yourself?"
  • Ask specifically about headache treatment:
    • Paracetamol
    • NSAIDs
    • Triptans
    • Combination analgesics
    • Opioids
  • Frequency of analgesia: "How many days each month do you take medication for your headaches?"

    Frequent use of acute headache medication can cause or perpetuate medication-overuse headache.

  • Ask about hormonal contraception or HRT where relevant
  • Ask about anticoagulants and antiplatelet medication
  • Allergies: medication + reaction

9. 👨‍👩‍👧‍👦 Family History

  • Migraine or recurrent headache disorders
  • Stroke or cerebrovascular disease
  • Intracranial aneurysm or subarachnoid haemorrhage where relevant
  • Neurological conditions

10. 🏠 Social History

  • Occupation: impact of headaches on work or study
  • Smoking: current or previous
  • Alcohol: amount and frequency
  • Recreational drugs
  • Caffeine: amount and recent changes
  • Hydration
  • Meals: missed or irregular meals
  • Sleep: quantity, quality and changes
  • Stress: work, home or emotional triggers
  • Menstrual relationship where relevant: "Have you noticed whether the headaches occur around your periods?"
  • Functional impact:
    • Work or education
    • Exercise
    • Sleep
    • Driving
    • Family or social activities

11. 💬 ICE - Ideas, Concerns & Expectations

  • "Do you have any thoughts about what might be causing the headaches?"
  • "Is there anything in particular you're worried this could be?"
  • "What were you hoping we could help you with today?"

12. 🧾 Summarise & Explain Next Steps

"So, you've had (duration) of (site/character) headaches occurring (frequency). They usually last (duration) and are associated with (symptoms). They are triggered by (trigger) and you have/have not had any concerning symptoms such as (important negatives)".

"I'd like to examine you and then decide whether any further investigations are needed based on the type of headache and the findings".

🔎 Targeted next steps
  • Full observations if clinically indicated
  • Blood pressure
  • Focused neurological examination
  • Cranial nerve examination
  • Gait and coordination assessment where indicated
  • Fundoscopy where raised intracranial pressure or visual pathology is suspected
  • Visual acuity and eye assessment where indicated
  • Neck examination where meningism is suspected
  • Temporal artery assessment if giant cell arteritis is suspected
  • Headache diary for recurrent primary headaches
🚨 Urgent escalation

A thunderclap headache, new neurological deficit, altered consciousness, meningism, suspected acute glaucoma, concerning visual symptoms or another serious secondary headache pattern requires urgent assessment through the appropriate emergency pathway.

13. 🔬 Investigations - Think Targeted

  • Uncomplicated primary headache: investigation is often unnecessary when the history and examination are reassuring.
  • Blood tests: order according to the suspected secondary cause rather than routinely for every headache.
  • Suspected giant cell arteritis: consider inflammatory markers and follow the urgent local GCA pathway.
  • Suspected subarachnoid haemorrhage: requires emergency assessment and appropriate neuroimaging through secondary care.
  • Suspected intracranial pathology: neuroimaging and/or specialist referral depends on the clinical presentation and urgency.
  • Do not request neuroimaging simply for reassurance when the presentation is consistent with a primary headache and there are no concerning features.

🎓 Present Back to Examiner (PA Format)

"This is a (age)-year-old (man/woman) presenting with a (duration) history of (episodic/progressive) headaches. The pain is predominantly (site), described as (character), with a severity of (x/10) and typically lasts (duration). It occurs approximately (frequency) and is associated with (relevant symptoms). There are no features of (key red flags). Relevant background includes (PMH/medication history). My leading differential is (diagnosis), with (diagnosis 2) and (diagnosis 3) also considered. I would perform a focused neurological examination including cranial nerves, observations and fundoscopy where indicated, and arrange investigations or referral according to any secondary headache features".

📚 Key References

  • NICE CG150 - Headaches in over 12s: diagnosis and management. Updated 2025.
  • NICE NG127 - Suspected neurological conditions: recognition and referral.
  • NICE NG228 - Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management.