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

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.



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