How to Assess Headache: A Step-by-Step Guide for Healthcare Professionals

Headaches are among the most common complaints encountered in clinical practice. As a healthcare professional, accurately assessing a headache is crucial for diagnosis and management. This comprehensive guide delves into the various aspects of headache assessment, offering practical insights and tools for medical students and healthcare professionals to approach this prevalent condition with confidence.

Understanding Headache Classification

Headaches can be broadly classified into two categories: primary and secondary headaches.

Primary Headaches: These are not associated with any other medical condition and include:

• Migraine: Characterized by throbbing pain, often on one side of the head, and accompanied by nausea, vomiting, and sensitivity to light or sound.
• Tension-Type Headache (TTH): Often described as a tight band around the head, these headaches are typically bilateral and may be associated with stress or muscle tension.
• Cluster Headache: Known for its severe, unilateral pain, often around the eye, cluster headaches occur in cyclical patterns or clusters.

Secondary Headaches: These are due to an underlying medical condition, such as:

• Infections: Sinusitis, meningitis, or encephalitis can cause headaches.
• Vascular Disorders: Conditions like aneurysms, arteriovenous malformations (AVMs), or stroke.
• Trauma: Head injuries, including concussions or more severe brain injuries.
• Substance Use or Withdrawal: From medications, caffeine, or alcohol.

The Importance of a Detailed Patient History

Taking a thorough patient history is the cornerstone of headache assessment. Key areas to explore include:

1. Onset:
   • Sudden or Gradual? A sudden, severe headache may indicate a serious condition like a subarachnoid hemorrhage, whereas a gradual onset is more typical of migraines or tension-type headaches.
   • First Occurrence or Recurrent? New-onset headaches in patients over 50 years old warrant further investigation for possible secondary causes.
2. Location:
   • Unilateral or Bilateral? Migraines are often unilateral, while tension-type headaches are typically bilateral.
   • Specific Areas Involved: For example, orbital pain might suggest cluster headaches.
3. Duration and Frequency:
   • How Long Does the Headache Last? Cluster headaches have short but frequent episodes, while migraines can last from hours to days.
   • Frequency of Occurrence: Chronic daily headaches often suggest overuse of medications or a transformed migraine.
4. Intensity and Quality of Pain:
   • Pain Scale: Use a 1-10 scale to assess the intensity.
   • Type of Pain: Throbbing, sharp, dull, or pressure-like can provide clues to the diagnosis.
5. Associated Symptoms:
   • Neurological Symptoms: Aura, vision changes, or focal neurological deficits may indicate migraines or more serious conditions like a stroke.
   • Systemic Symptoms: Fever, weight loss, or neck stiffness can suggest infections, temporal arteritis, or meningitis.
6. Triggers and Alleviating Factors:
   • What Precipitates the Headache? Certain foods, stress, or changes in sleep patterns are common migraine triggers.
   • What Relieves the Pain? Response to analgesics or triptans can be indicative of the type of headache.
7. Family History:
   • Any Similar Conditions in the Family? A family history of migraines is common, and this information can help narrow down the diagnosis.

Physical Examination: Key Areas to Focus On

A physical examination for a patient presenting with a headache should be comprehensive, with particular attention to the following areas:

1. Vital Signs:
   • Blood Pressure: Hypertension can be both a cause and a consequence of headaches.
   • Temperature: Fever may indicate an infectious cause of headache.
2. Head and Neck Examination:
   • Scalp Tenderness: Particularly in patients with suspected temporal arteritis.
   • Sinus Tenderness: Suggestive of sinusitis.
   • Neck Stiffness: A critical sign of meningitis or subarachnoid hemorrhage.
3. Neurological Examination:
   • Cranial Nerve Assessment: Look for any deficits that could indicate a mass lesion or increased intracranial pressure.
   • Motor and Sensory Function: Any asymmetry could suggest a stroke or other serious condition.
   • Coordination and Gait: Cerebellar signs could indicate posterior fossa lesions.
4. Fundoscopic Examination:
   • Papilledema: Indicates increased intracranial pressure, which requires urgent investigation.

Diagnostic Investigations: When and What to Order

While the history and physical examination often point towards the diagnosis, certain investigations may be necessary to confirm or rule out other conditions:

1. Neuroimaging:
   • CT Scan: Useful for detecting acute hemorrhages, large tumors, or hydrocephalus. It is often the first imaging modality ordered in the emergency setting.
   • MRI: Provides greater detail for diagnosing conditions like small tumors, demyelinating diseases, or vascular malformations.
2. Lumbar Puncture:
   • Indicated in Suspected Meningitis: When meningitis is suspected, especially if accompanied by fever, neck stiffness, or altered mental status.
   • Subarachnoid Hemorrhage: If the CT scan is negative and suspicion remains high.
3. Blood Tests:
   • Complete Blood Count (CBC): To check for infection or anemia.
   • C-Reactive Protein (CRP) or Erythrocyte Sedimentation Rate (ESR): Elevated in cases of temporal arteritis.
   • Electrolyte Panel: To rule out metabolic causes of headaches.
4. Specialized Tests:
   • Temporal Artery Biopsy: For suspected temporal arteritis.
   • Electroencephalogram (EEG): If seizures are suspected in the differential diagnosis.

Common Types of Headaches: Diagnosis and Management

1. Migraine:

• Diagnosis: Often clinical, based on criteria from the International Classification of Headache Disorders (ICHD).
• Management:
  • Acute Treatment: NSAIDs, triptans, and antiemetics.
  • Preventive Treatment: Beta-blockers, antiepileptic drugs, and certain antidepressants.
  • Lifestyle Modifications: Stress management, regular sleep, and diet control.

2. Tension-Type Headache:

• Diagnosis: Characterized by bilateral, non-pulsating pain, often described as a tight band around the head.
• Management:
  • Acute Treatment: NSAIDs or acetaminophen.
  • Chronic Management: Antidepressants and cognitive-behavioral therapy (CBT).

3. Cluster Headache:

• Diagnosis: Based on the characteristic episodic nature and associated autonomic symptoms like lacrimation and nasal congestion.
• Management:
  • Acute Treatment: High-flow oxygen and triptans.
  • Preventive Treatment: Verapamil, corticosteroids, and sometimes lithium.

4. Secondary Headaches:

• Diagnosis: Requires identification and treatment of the underlying cause.
• Management: Treat the underlying condition, such as antibiotics for infections, surgical intervention for aneurysms, or cessation of causative medications.

Red Flags in Headache Assessment

Recognizing "red flags" is critical in headache assessment. These warning signs suggest the possibility of a serious underlying condition and warrant immediate investigation:

• Sudden Onset: A "thunderclap" headache that reaches maximum intensity within minutes.
• New Onset After Age 50: Raises suspicion for conditions like temporal arteritis or malignancy.
• Neurological Deficits: Any focal neurological signs or symptoms.
• Systemic Symptoms: Fever, weight loss, or a history of cancer or immunosuppression.
• Altered Mental Status: Confusion, reduced consciousness, or seizures.
• Postural Component: Headache that changes with position, suggesting raised intracranial pressure or cerebrospinal fluid (CSF) leak.
• Triggered by Valsalva Maneuver: Coughing, sneezing, or straining can exacerbate headaches caused by increased intracranial pressure.

Conclusion: Best Practices in Headache Assessment

Assessing headaches requires a systematic approach, combining detailed history, focused physical examination, and appropriate investigations. By recognizing the common types of headaches and the associated red flags, healthcare professionals can ensure accurate diagnosis and effective management. Always consider secondary causes, especially in atypical presentations, and do not hesitate to order appropriate investigations when necessary.

This comprehensive guide provides a solid foundation for medical students and healthcare professionals in the assessment of headaches, promoting accurate diagnosis and patient-centered care.