- How many different types of headache do you get? Patients can identify separate headaches. Examine each one in turn.
- Time questions: why are they consulting now? How recent is the onset? The temporal pattern?
- Character questions: intensity; nature and quality; sight; associated symptoms (particularly nausea, phonophobia, photophobia, movement sensitivity).
- Cause questions: predisposing or trigger factors; family history of similar headache.
- Response questions: what do you do when you get a headache? (tension-type headache - keeps going; migraine - wants to lie down; cluster headache - wants to bang their head against a wall). What medication has been and is being used?
- State of health between attacks. Concerns, comorbid anxiety or depression.
|What do patients want?|
The headache examination
Fundoscopy and BP measurements are minimal. The examination box shows a simple examination pro forma excluding most pathologies. Subtle neurological nuances are rarely helpful in the examination.
Headache diaries are invariably useful. Scores, such as the migraine disability assessment and the headache impact test, can assess impact and monitor treatment.
- FBC - anaemia, leukaemia and infection can cause headache.
- ESR and CRP - if raised can indicate temporal arteritis or systemic disease.
- Creatinine - renal failure can cause headache.
- Calcium - to exclude hypercalcaemia.
- TFT - headache can be associated with hypothyroidism.
- LFT - could indicate metastatic disease.
- Carbon monoxide level where relevant.
- Venereal disease research laboratory (syphilis) test.
- Lyme antibodies.
- Antinuclear antibodies, lupus anticoagulant, anticardiolipin antibodies.
- CT is more accurate for haemorrhage up to five days after the event but will miss around 10 per cent of space- occupying lesions, especially in the posterior fossa.
- Ten per cent of patients will experience problems with claustrophobia with MRI.
- Three per cent will show incidental abnormalities, which invariably give cause for unnecessary concern.
Red flags signify presentations where the probability of an underlying tumour is likely to be greater than 1 per cent. These warrant urgent investigation. Headache with:
- Papilloedema or focal neurological signs.
- Alterations in consciousness, memory or co-ordination.
- New-onset cluster headache (imaging, particularly of the region of the pituitary fossa, required but non-urgent).
- A history of cancer elsewhere particularly breast and lung.
Orange flags occur in presentations where the probability of an underlying tumour is between 0.1 and 1 per cent. These need careful monitoring and a low threshold for investigation.
- Where a diagnostic pattern has not emerged after eight weeks from presentation.
- Aggravated by exertion or valsalva manoeuvre.
- Has been present for some time but has changed significantly, particularly a rapid increase in frequency.
- Wakes the patient from sleep.
- New headache in the over 50s.
Dr Kernick is a GP in Exeter, Devon, and RCGP headache clinical champion
- For videos relating to this fact file, see www.rcgp.org.uk/clinical_and_research/circ/clinical_priorities/headac he/headache_fact_sheets.aspx
Risks of headache associated with a tumour
A simple pro forma for a headache examination
- Diagnosis and management of headache in adults. SIGN www.sign.ac.uk/guidelines/fulltext/107/index.html
- The British Association for the Study of Headache www.bash.org.uk
- Exeter headache clinic website www.exeterheadacheclinic.org.uk Contains clinical guidance and patient drug information treatment sheets.
Patient support groups