Taking a headache history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a headache history in an OSCE setting. Show
The vast majority of headaches are not life-threatening, with tension headache and migraine being the most common diagnoses. However, in some cases, a headache may be the first indication of serious underlying pathology and therefore it is essential you are able to take a comprehensive headache history. Download the headache history taking PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our loss of consciousness and stroke history taking guides. Opening the consultationWash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth. Explain that you’d like to take a history from the patient. Gain consent to proceed with history taking. General communication skillsIt is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient). Some general communication skills which apply to all patient consultations include:
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. Presenting complaintUse open questioning to explore the patient’s presenting complaint:
Provide the patient with enough time to answer and avoid interrupting them. Facilitate the patient to expand on their presenting complaint if required:
Open vs closed questionsHistory taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. History of presenting complaintSOCRATESThe SOCRATES acronym (explained below) is a useful tool that you can use to further explore the characteristics of the patient’s headache. SiteAsk about the location of the headache:
Migraines typically present as a unilateral headache whereas bilateral headache is most commonly associated with a tension headache. OnsetClarify how and when the headache developed:
Headaches that have a very sudden onset, reaching their maximum intensity within seconds are typically associated with subarachnoid haemorrhage (often described as ‘thunderclap’ in nature). CharacterAsk about the specific characteristics of the headache:
Common descriptors of headaches may include: ‘aching’, ‘throbbing’, ‘pounding’, ‘pulsating’, ‘pressure’, ‘pins and needles’ and ‘stabbing’. RadiationAsk if the headache moves anywhere else:
The radiation of a headache to another anatomical location may help to narrow the differential diagnosis:
Associated symptomsAsk if there are other symptoms which are associated with the headache:
See the key symptoms section below for examples. Time courseClarify how the headache has changed over time:
Headaches that are worse in the mornings are suggestive of raised intracranial pressure (e.g. space-occupying lesion). Exacerbating or relieving factorsAsk if anything makes the headaches worse or better:
Triggers for headaches may include caffeine, excessive codeine use, stress, coughing (suggestive of raised ICP), lying flat (suggestive of raised ICP) and standing up (suggestive of low ICP). Relieving factors for headaches may include hydration, standing up (suggestive of raised ICP) and lying down (suggestive of low ICP). SeverityAssess the severity of the headaches by asking the patient to grade it on a scale of 0-10:
Ask the patient how the headaches are affecting their daily life. Regular migraines may make it difficult for the patient to function. Key symptoms to ask aboutKey symptoms to ask about when taking a headache history include:
Red flag featuresIt is important that you recognise red flag features in a headache history which warrant urgent further investigation. Examples of some red flag presentations include:
Ideas, concerns and expectationsA key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic. It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below. IdeasExplore the patient’s ideas about the current issue:
ConcernsExplore the patient’s current concerns:
ExpectationsAsk what the patient hopes to gain from the consultation:
SummarisingSummarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. SignpostingSignposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next. Signposting examplesExplain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.” What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.” Systemic enquiryA systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint. Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience. Some examples of symptoms you could screen for in each system include:
Past medical historyAsk if the patient has any medical conditions:
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions. Ask if the patient has previously undergone any surgery or procedures (e.g. neurosurgery):
AllergiesAsk if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis). Examples of relevant medical conditionsMedical history relevant to headaches includes:
Drug historyAsk if the patient is currently taking any prescribed medications or over-the-counter remedies:
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Specifically ask about blood-thinning medications such as aspirin, warfarin and NOACs (e.g. apixaban). Ask the patient if they’re currently experiencing any side effects from their medication:
Ask the patient if they are using any medication to treat their headaches and gather details of how frequently they are using these medications:
Medication-overuse headacheMedication overuse headache is counterintuitively associated with medications used for the treatment of headache. Overuse of these medications is defined as use on more than 15 days of a month. Medications which are associated with medication-overuse headaches include:
Family historyAsk the patient if there is any family history of headaches, cancer, bleeds on the brain, clotting disorders or bleeding disorders:
Clarify at what age these diseases developed (disease developing at a younger age is more likely to be associated with genetic factors):
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:
Social historyExplore the patient’s social history to both understand their social context and identify potential risk factors for headaches. General social contextExplore the patient’s general social context including:
SmokingRecord the patient’s smoking history, including the type and amount of tobacco used. Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk profile:
Smoking is an important risk factor for both malignancy and thrombotic disease. AlcoholRecord the frequency, type and volume of alcohol consumed on a weekly basis. Alcohol can cause headaches, particularly when used excessively. Patients may also experience alcohol withdrawal headaches. Recreational drug useAsk the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Headaches can be associated with the use of cocaine, amphetamines and cannabis. OccupationAsk about the patient’s current occupation:
Closing the consultationSummarise the key points back to the patient. Ask the patient if they have any questions or concerns that have not been addressed. Thank the patient for their time. Dispose of PPE appropriately and wash your hands. What questions related to the history of present illness should a nurse ask a patient?History of Present Illness
o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse • Any other symptoms that you have?
Which elements of the patients history should the nurse ask about to gain more information related to present illness?Patient history
Nursing staff should discuss the history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history.
Which head assessment findings would be considered abnormal?Abnormal findings include: Discharge, lesions, abnormal light reflection on tympanic membrane, scarring of the tympanic membrane.
Which nose assessment findings should be considered abnormal?Normal findings might be documented as: “External nose is symmetrical with no discolouration, swelling or malformations. Nasal mucosa is pinkish red with no discharge/bleeding, swelling, malformations or foreign bodies.” Abnormal findings might be documented as: “Bright red nasal mucosa with purulent discharge.”
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