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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