Headache assessment

HPI

• FIRST or WORST headache ever?
• DIFFERENT from usual headaches?

• Onset = when did it start?
  • gradual, sudden (thunder-clap)
  • prodrome, aura
• Palliation/Provocative
  • stress, food, menstrual cycle, rest
• Quality
  • unilateral, bilateral, band-like?
  • does it spread?
  • throbbing, stabbing, dull, pressure
• Radiation
  • where does it spread?
• Severity
  • Nausea/vomiting
  • photo/phonophobia
  • vision changes
  • fever
  • stiff neck
  • confusion

Review of systems:

• General systemic illness: weightloss
• CNS: change in mentation, personality, aura

RED FLAGS OF SERIOUS HEADACHES

New onset

• headaches beginning at age 40
  • mass lesion, temporal arteritis

More SEVERE and FREQUENT headaches (worst headache ever)

• mass lesion, subdural hematoma, medication overuse, post-coital headache/migraine

SUDDEN onset (maximal at onset - no increase over time)

• SAH, mass lesion (especially in the posterior fossa)
• new onset in patient with risk factors for HIV or CANCER
  • meningitis, brain abscess, metastasis

headache ASSOCIATED with

• fever (meningitis, encephalitis, systemic infection)
• projectile vomiting
• impaired mental status
• focal neurological signs - weakness, paresthesia (mass lesion, stroke)
• recent head injury
• papilledema (mass lesion, pseudotumor, meningitis)
• meningismus (meningeal irritation)
• seizures
• trauma (intracranial hemorrhage, subdural/epidural hematoma, SAH)

PMHx

• Hypertension
• HIV
• Cancer
• Trauma
• Recent procedures

Medication

• Analgesic abuse
• Recreational drugs
• Birth control

Family history

• Migraines
• Subarachnoid hemorrhage
• Stroke