Headache history Taking | OSCE Tips

What brought you here today?

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)

Is there any chronic illness that I should know about that we have not covered?

Do you have any allergies I should know about?

Are you taking any medication? If so, any side effects.

Have you tried any previous medications for your headache? If yes, has it helped?

Is there any family history of headache, bleeding disorders, brain cancer I should know about?

Do you smoke? Any alcohol? Any recent travel? Occupation?

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 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

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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