Headache history Taking | OSCE Tips
Presenting complaint (PC):
What brought you here today?
History presenting complaint (HPC):
Site: Can you tell me where you feel the headache? (generalised, unilateral, bilateral, fronta, occipital, temporal, parietal, sinus headache)
Onset: when did it start? (sudden, gradual: minutes, hours, days, variable?)
Character: can you tell me how it feels? ( Aching, throbbing, shooting, morning headache, heavy head)
Radiation: does the headache move anywhere else?
Associated symptoms: any visual disturbance? Any hearing loss? Any change of smell/taste? Any nausea/vomiting?
Timing: How long does the headache last for? (seconds, minutes, hours, days)
Exacerbating/relieving factors: does anything make it worse or better?
Severity: where would you put the pain, 1-10. Ten being the worst?
Now is a good idea to ask Ideas, Concerns & Expectations (ICE)
Past medical history (PMH):
Is there any chronic illness that I should know about that we have not covered?
Allergies:
Do you have any allergies I should know about?
Drug history (DH):
Are you taking any medication? If so, any side effects.
Have you tried any previous medications for your headache? If yes, has it helped?
Family history (FMH):
Is there any family history of headache, bleeding disorders, brain cancer I should know about?
Social History (SH):
Do you smoke? Any alcohol? Any recent travel? Occupation?
Possible differential diagnosis:
Tension headache - tight band, recurrent, late day?, stress?
Cluster headache - short painful attack in one eye, last 30 min - 3hr, lacrimation + flushing
Migraine - unilateral pulsating earache in trigeminal distribution, last few hours to days, may have aural (visual?), photophobia. Last 4 - 72 hr, at least 5 attacks. 15 episodes x month is defined as chronic migraine. At least for 3 months.
Trigeminal neuralgia - 2sec stabbing pain, face screws up in pain.
Meningitis - photophobia, neck stiffness, fever, non blanching rash
Temp arthritis - unilateral throbbing pain , scalp tenderness + jaw claudication, >55 years, visual disturbances
Sub haemorrhage - sudden onset severe headache, brick over head
Raised Intracranial pressure (ICP) - worse in morning + cough and bending, vomiting, reduced GCS, seizure?? Immunocompromised
Red flag symptoms:
Red flag signs for a headache sufferer are numerous and difficult to list completely below are some examples:
Subarachnoid haemorrhage or intracranial bleed: New severe headache: sudden onset severe headache “thunderclap” max intensity in 5 minutes.
Space occupying lesion or subdural haematoma: progressive/persistent headache lasting weeks with focal neurological symptoms such as change in movement, paralysis, loss of muscle control and tone, numbness or decreased sensation.
Temporal arteritis: Visual disturbance + jaw claudication + scalp tenderness
Investigation:
Bedside: Cranial nerve/neurological examination, Oxygen saturation (SPO2), pulse/heart rate (HR), blood pressure (BP), respiratory rate (RR), tympanic temperature, fundoscopy
Bloods : No specific blood test, can request if you are considering secondary causes
Imaging: CT/MRI if considering malignancy but generally you should refer 2ww wait
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