Assessment of the adolescent or adult with headache follows much what has been described previously for children. The main difference is that there are some age-specific causes to be considered.

Nice describe a stepwise approach to assessment:-

  • Asses the possibility that more than one headache disorder is present

  • Assess for symptoms of:-

    • Serious secondary causes

    • Medication overuse

    • Tension-type and migraine headaches

  • Examine for secondary causes

  • If the cause cannot be diagnosed

    • Use a headache diary

    • Consider referral for assessment

The initial history should ask as a minimum

  • Is there one or more than one type of headache?

  • When did they start?

  • How frequent?

  • How long does it last?

  • Site of headache? – Is there more than one site?

  • Intensity of pain?

  • Precipitating factors?

  • What makes the pain worse?

  • What makes the pain better?

  • Medicine use/overuse?

  • Associated symptoms

    • Visual disturbance (when?)

    • Nausea or vomiting

    • Dizziness or lightheaded

    • Abdominal pain

  • Well between attacks?

  

Examination should include

  • Measurement of blood pressure.

  • Palpation of the temporal arteries, if the person is more than 50 years of age.

  • A neurological examination, including fundoscopy for papilloedema.

  • Examination of the neck for muscular tenderness, stiffness and limitations of movement.

A headache diary can be downloaded here

A visual analogue scale for severity of pain can be downloaded here

Patterns of headaches

Patterns of Headaches

Pattern 1 is known as chronic non- progressive. It is the pattern seen with the primary headaches known as tension-type. Although tension type headache can indeed be psychogenic in its aetiology, many other factors can be involved.

Pattern 2 is known as chronic progressive. This is a red flag pattern and should trigger prompt referral for investigation. It is seen in Hydrocephalus, Brain Tumour, Brain Abscess and Benign Intracranial Hypertension.

Pattern 3 is typical of migraine; further classification will depend on other symptoms noted in the headache diary.

Pattern 4 is acute on chronic non-progressive and the possibility of co-existing migraine with background tension headache should be considered.

 

 

BASH list the warning features in the history as:-

  • Headache that is new or unexpected in an individual patient

  • Thunderclap headache (intense headache with abrupt or “explosive” onset)

  • Headache with atypical aura (duration >1 hour, or including motor weakness)

  • Aura occurring for the first time in a patient during use of combined oral contraceptives

  • New onset headache in a patient older than 50 years

  • New onset headache in a patient younger than 10 years

  • Persistent morning headache with nausea

  • Progressive headache, worsening over weeks or longer

  • Headache associated with postural change

  • New onset headache in a patient with a history of cancer

New onset headache in a patient with a history of HIV infection.