🩺 MedAtlax

Search

SearchSearch

Headache Hx OSCE

Apr 06, 202513 min read

Headache - OSCE

Table of Contents

History Taking * Presenting Complaint & Analysis * Specific Headache Type Differentiation * Migraine Specifics (Risk Factors, Aura) * Red Flag Symptom Exclusion * Secondary Cause Exclusion (Beyond Red Flags) * Past Medical & Surgical History * Medication History & Allergies * Family History * Social & Lifestyle History * Psychiatric History * Specific History Points (Female/Geriatric) * Patient’s Perspective (ICE) & Functional Impact * Summarization * Differential Diagnosis * Primary Headaches * Secondary Headaches * Clinical Examination * Investigations * Management Plan * Diagnosis Explanation, Education & Reassurance * Non-Pharmacological Management & Advice * Pharmacological Management * Tension Headache * Migraine Headache * Cluster Headache * Shared Decision Making & Understanding * Referral Criteria * Follow-up, Safety Netting & Health Education

Candidate Expectations & Key Areas to Cover

General OSCE Skills / Doctor-Patient Interaction

  • Professional Behavior & Rapport:
    • Introduce self clearly, confirm patient identity.
    • Build rapport effectively (good posture, respectful tone, appropriate body language).
    • Demonstrate interest, concern, and respect throughout. Show empathy. Maintain good eye contact.
  • Communication Techniques:
    • Use a mix of open-ended and closed questions appropriately and in sequence.
    • Listen attentively, allow patient time to respond, avoid interruptions.
    • Use facilitation techniques (verbal/non-verbal encouragement, silence, nodding).
    • Use concise, easily understood language; avoid or explain medical jargon.
    • Periodically summarize (“Internal Summary”) to check understanding and invite corrections.
  • Patient-Centered Approach:
    • Actively elicit the patient’s Ideas, Concerns, and Expectations (ICE) and the effect of the headache on their life/function.
    • Encourage the patient to talk and express their views.
    • Promote informed, shared decision-making regarding the management plan.
  • Structure & Timing:
    • Maintain a logical flow throughout the consultation.
    • Attend to timing.

History Taking

HOPI

Presenting Complaint & Analysis

  • Initiation: Start with an open-ended question (e.g., “Tell me about your headache”).
  • Headache Characteristics: Explore thoroughly:
    • Onset: When did it start? First time?
    • Course: Getting worse/better/staying the same? Continuous or episodic?
    • Frequency: How often do the headaches occur?
    • Duration: How long does each headache last?
    • Site: Where exactly is the pain? (Unilateral, bilateral, frontal, temporal, occipital, over sinuses, band-like).
    • Radiation/Spread: Does the pain travel anywhere?
    • Character/Nature/Quality: Describe the pain (e.g., throbbing, pounding, sharp, pressure, dull ache, stabbing).
    • Severity/Intensity: How bad is the pain (e.g., scale of 1-10)? Does it interfere with activities?
    • Timing: Any specific time of day? Pattern?
    • Aggravating Factors: What makes it worse? (e.g., movement, light, sound, stress, specific foods, caffeine, lack of sleep, chewing).
    • Relieving Factors: What makes it better? (e.g., rest, darkness, medication, vomiting).
    • Associated Symptoms: Nausea, vomiting, photophobia (light sensitivity), phonophobia (sound sensitivity), visual disturbances (aura), dizziness, vertigo, fever, seizures, diplopia (double vision), decreased vision, facial pain, ear pain, eye pain/redness, tearing eyes, nasal congestion, neck stiffness, rash, weakness, numbness, tingling, difficulty speaking.
    • Previous Attacks: History of similar headaches? What action was taken previously?
    • State Between Attacks: How does the patient feel between headache episodes? (Completely well?)

Specific Headache Type Differentiation

  • Ask specific questions to differentiate between primary headache types:
    • Migraine: Unilateral, throbbing, moderate/severe intensity, aggravated by activity, associated nausea/vomiting, photophobia/phonophobia, possible aura.
    • Tension: Bilateral, pressure/tightening (band-like), mild/moderate intensity, not aggravated by routine activity, usually no nausea (though anorexia possible), photophobia OR phonophobia may be present but not both usually. Often related to stress.
    • Cluster: Severe unilateral orbital, supraorbital, or temporal pain, lasting 15-180 mins. Associated ipsilateral autonomic symptoms (conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, ptosis, eyelid edema). Restlessness/agitation. Occur in clusters.

Migraine Specifics (Risk Factors, Aura)

  • Aura: Specifically inquire about visual disturbances (flashing lights, zig-zag lines, blind spots), sensory symptoms (tingling, numbness), or motor symptoms (weakness - hemiplegic migraine) preceding the headache.
  • Migraine Triggers/Risk Factors: Lack of sleep, stress, specific foods/diet (e.g., chocolate, cheese, nitrates), caffeine (intake or withdrawal), hormonal changes (menstruation), weather changes.

Red Flag Symptom Exclusion

  • Actively ask about and rule out “sinister” features suggesting a serious underlying cause:
    • Systemic Symptoms: Fever, weight loss, fatigue, poor appetite (suggests infection, malignancy, arteritis). History of cancer. HIV/Immunocompromised state.
    • Neurologic Symptoms/Signs: Confusion, impaired consciousness, seizures, focal neurological deficits (weakness, numbness, diplopia, visual loss, difficulty speaking - suggests stroke, TIA, mass, bleed, meningitis/encephalitis). Papilledema (requires fundoscopy).
    • Onset: Sudden, abrupt, “thunderclap” onset (worst headache ever - suggests Subarachnoid Hemorrhage - SAH).
    • Older Age: New onset headache or change in pattern in patient > 50 years (higher risk of Temporal Arteritis, malignancy).
    • Pattern Change/Previous History: Change in frequency, severity, or characteristics from previous headaches. Positional headache (worse standing/sitting up - CSF leak; worse lying down - raised ICP). Precipitated by Valsalva (coughing, sneezing, exertion - suggests posterior fossa lesion, Chiari malformation, raised ICP). Post-traumatic onset (recent head trauma, injury, concussion). Progressive headache worsening over time.

Secondary Cause Exclusion (Beyond Red Flags)

  • Medication Overuse Headache: Frequency and type of analgesic intake (NSAIDs, paracetamol, triptans, opioids). Taking acute pain meds >10-15 days/month?
  • Sinusitis: Pain over sinuses, fever, post-nasal discharge, facial pressure.
  • Temporal Arteritis (Giant Cell Arteritis): Age >50, new headache, temporal artery tenderness/pulselessness, jaw claudication (pain with chewing), visual symptoms, polymyalgia rheumatica symptoms (shoulder/hip girdle pain/stiffness).
  • Glaucoma: Red, painful eye, blurred vision, halos around lights, nausea/vomiting, abdominal pain.
  • Meningitis: Fever, neck rigidity, vomiting, rash, altered mental status.
  • Brain Tumor: Headache often worse in the morning, may wake from sleep, associated vomiting, progressive neurological symptoms, personality change.
  • TIA/Stroke: Transient or persistent neurological deficits.
  • Trigeminal Neuralgia: Brief, electric shock-like facial pain triggered by touching face, chewing, talking.
  • Referred Pain: From teeth, ears, neck (cervical spondylosis).
  • Anemia: Pallor, fatigue, palpitation, dizziness. (Less common direct cause, more associated symptom).

Past Hx

Past Medical & Surgical History

  • Any chronic diseases (e.g., Hypertension, Diabetes Mellitus, CAD, ASCVD risk factors, autoimmune diseases, malignancies, psychiatric diseases).
  • Previous head trauma or surgery. Any other surgeries.

Medication History & Allergies

  • Current medications (prescription, OTC - especially analgesics, NSAIDs, paracetamol).
  • Herbal drugs.
  • Oral Contraceptive Pills (OCP).
  • History of blood transfusion.
  • Allergies (especially to medications).

Family History

  • History of similar headaches (especially migraine).
  • Family history of autoimmune disease, malignancies, psychiatric diseases, or other chronic illnesses.

Social & Lifestyle History

  • Occupation: Type of work, stress levels at work.
  • Marital Status & Family: Relationships with family members, support system.
  • Stress: General life stressors, coping mechanisms.
  • Diet: Regularity of meals, specific trigger foods, caffeine intake.
  • Sleep: Sleep patterns, quality, duration.
  • Exercise: Level of physical activity.
  • Substance Use: Smoking, alcohol intake.
  • Travel History: Recent travel?

Psychiatric History

  • Screen for depression (low mood, loss of interest/pleasure - anhedonia, sleep changes, appetite changes, fatigue, concentration issues). Ask “Are you happy?“.
  • Screen for anxiety (excessive worry, racing thoughts).

Specific History Points (Female/Geriatric)

  • If Female: Menstrual history (relation of headaches to cycle), obstetric history, contraceptive history (especially OCP use).
  • If Female or Geriatric: Consider adding screening questions for abuse (physical, verbal, sexual) sensitively if appropriate contextually.

Patient’s Perspective (ICE) & Functional Impact

  • Ideas: “What do you think might be causing these headaches?”
  • Concerns: “Is there anything specific that worries you about them?”
  • Expectations: “What were you hoping we could do for you today?”
  • Functional Impact: Explore how the headaches affect daily activities, work, social life, mood.

Summarization

  • Summarize the key points of the history back to the patient.
  • Ask: “Have I missed anything?” or “Is there anything else you’d like to add?”

Differential Diagnosis

Primary Headaches

  • Migraine: With or without aura (visual flashes, vomiting, nausea, diplopia, dizziness, decreased vision, photophobia, phonophobia).
  • Tension-Type Headache: Pressure, band-like, often related to stress.
  • Cluster Headache: Severe unilateral eye/temporal pain with autonomic features (tearing, nasal congestion).
  • Hemiplegic Migraine: Migraine with associated unilateral weakness, tingling, numbness.

Secondary Headaches

  • Sinusitis Headache: Pain over sinuses, fever, post-nasal discharge.
  • Medication Overuse Headache: Due to frequent analgesic use.
  • Temporal Arteritis (GCA): Age >50, jaw claudication, tender temporal artery.
  • Post-traumatic Headache: Following head injury/concussion.
  • Glaucoma: Red painful eye, visual changes.
  • Meningitis/Encephalitis: Fever, neck stiffness, altered consciousness.
  • Brain Tumor: Progressive headache, neurological signs, morning vomiting.
  • Subarachnoid Hemorrhage (SAH): Sudden, severe “thunderclap” headache.
  • Transient Ischemic Attack (TIA) / Stroke: Associated neurological deficits.
  • Trigeminal Neuralgia: Facial pain triggered by touch.
  • Referred Pain: From teeth, ears, neck (cervical spondylosis).
  • Anemia-associated symptoms: Pallor, fatigue, dizziness (headache itself less specific).

Clinical ExaminationY

(Note: Tailor examination based on history and suspected diagnosis. State intention clearly.)

  • Preparation: Ask permission, explain the examination, ensure privacy, wash hands.
  • Vital Signs: Temperature, Blood Pressure (BP - comment if normal), Heart Rate (Pulse), Respiratory Rate. Calculate BMI.
  • General Examination:
    • Assess general appearance, consciousness level, distress.
    • Look for pallor (anemia), signs of systemic illness, rash.
  • Focal Examination (Guided by History):
    • Head & Neck:
      • Inspect and palpate head/scalp for tenderness, lesions.
      • Palpate temporal arteries (tenderness, thickening, reduced pulse - if suspecting GCA).
      • Palpate sinuses for tenderness (if suspecting sinusitis).
      • Check neck range of motion, palpate for tenderness (cervical spondylosis). Check for neck rigidity (meningitis).
      • Listen over carotid arteries with diaphragm (bruits - though low yield for headache alone).
    • Neurological Examination:
      • Cranial Nerves: Especially II (visual acuity, visual fields, fundoscopy), III, IV, VI (eye movements, diplopia), V (facial sensation), VII (facial symmetry).
      • Fundoscopy: Check for papilledema (raised ICP), hemorrhages, exudates.
      • Motor system: Tone, power, reflexes, coordination (if focal symptoms).
      • Sensation: Test sensation (if focal symptoms).
      • Gait: Observe walking.
      • Meningeal Signs: Kernig’s, Brudzinski’s (if suspecting meningitis/SAH).
    • ENT Examination: Look in ears, nose, throat if referred pain suspected.
    • Lymph Nodes: Palpate cervical lymph nodes.
    • Cardiovascular System (CVS): Auscultate heart (briefly).
    • Musculoskeletal (MSK): Assess TMJ if relevant.

Investigations

(Note: Often not needed for primary headaches if no red flags. Guided by clinical suspicion.)

  • Blood Tests:
    • CBC: To exclude anemia or infection.
    • ESR/CRP: Elevated in Temporal Arteritis, infection.
  • Imaging:
    • CT Brain (usually non-contrast first): If suspecting acute bleed (SAH), trauma, tumor, sinusitis (CT sinuses). Indicated urgently if red flags present (thunderclap onset, focal neurology, impaired consciousness, papilledema, post-trauma, suspected meningitis/encephalitis).
    • MRI Brain: More sensitive for certain tumors, posterior fossa pathology, demyelination, vascular abnormalities. Consider if CT is normal but suspicion remains high or for chronic progressive headaches.
  • Lumbar Puncture (LP): If suspecting meningitis or SAH (after ruling out raised ICP with imaging). Check opening pressure, CSF analysis (cells, protein, glucose, microbiology, xanthochromia for SAH).
  • Other:
    • Consider Temporal Artery Biopsy if GCA suspected.

Management Plan

Diagnosis Explanation, Education & Reassurance

  • Explain the likely diagnosis (e.g., Migraine with aura, Tension-type headache) in simple terms based on the history and examination.
  • Explain the nature of the problem (e.g., Migraine is a neurological condition, Tension headache is often related to muscle tension/stress).
  • Reassure the patient, especially if red flags are absent and a primary headache is diagnosed. Explain it’s common and usually not dangerous, but can significantly impact quality of life.
  • Discuss the prognosis.
  • Appropriately respond to the patient’s specific concerns (elicited via ICE). Check understanding.

Non-Pharmacological Management & Advice

  • Identify and Avoid Triggers: Encourage keeping a headache diary to track headaches, symptoms, potential triggers (foods, stress, sleep changes, etc.), and medication use.
  • Lifestyle Modifications:
    • Sleep: Advise regular sleep schedule and adequate sleep duration (Have a good sleep).
    • Stress Management: Techniques like relaxation exercises, mindfulness, yoga, CBT if stress is a major factor.
    • Diet: Eat regular meals, stay hydrated (drink water), avoid known dietary triggers (e.g., caffeine withdrawal/excess, alcohol, aged cheeses, processed meats).
    • Exercise: Regular physical activity can help, but avoid overexertion which can trigger migraines for some.
  • Acute Migraine Attack Advice: Rest in a dark, quiet room, especially during aura or headache onset.
  • Contraception: If female on OCP and experiencing migraine (especially with aura), discuss stopping OCP due to increased stroke risk and changing the contraception method.

Pharmacological Management

(Tailor to headache type and severity. Discuss options, benefits, side effects)

Tension Headache
  • Acute: Simple analgesics.
    • Paracetamol 1000mg.
    • NSAIDs: Ibuprofen 400-800mg, Naproxen 500-1000mg initially. Caution: GI side effects, renal impairment, cardiovascular risk. Avoid overuse.
    • Aspirin (if appropriate).
  • Prophylactic: Consider if frequent (>15 days/month) or debilitating.
    • Amitriptyline: Low dose (e.g., 10-25mg at night, titrate up to 75-150mg). Side effects: sedation, dry mouth, constipation.
Migraine Headache
  • Acute (Mild-Moderate Attack):
    • Simple Analgesics: Paracetamol 1000mg, NSAIDs (Ibuprofen 400-800mg, Naproxen 500-1000mg, Diclofenac 50mg). Take at onset of headache.
    • Antiemetics: Metoclopramide 10mg (orally/IM/IV) or Domperidone. Can help with nausea/vomiting and improve absorption of analgesics. Metoclopramide max 5 days, risk of extrapyramidal side effects.
  • Acute (Moderate-Severe Attack or Failure of Simple Analgesics):
    • Triptans: (Serotonin 5-HT1B/1D agonists)
      • Sumatriptan: Oral (25-100mg, repeat after 2 hours if needed, max 200-300mg/24h depending on formulation), Subcutaneous injection (fastest onset), Intranasal spray.
      • Other triptans available (e.g., Rizatriptan, Zolmitriptan, Eletriptan) with varying pharmacokinetics.
      • Contraindications: Ischemic heart disease (IHD/CAD), uncontrolled hypertension, previous stroke/TIA, peripheral vascular disease, hemiplegic or basilar migraine, use within 24h of ergotamines or another triptan, use with MAOIs (for some triptans). Use paracetamol if contraindicated.
    • Ergotamines: (Less common now due to side effect profile)
      • Dihydroergotamine (DHE): IM, SC, IV, nasal spray. Contraindications similar to triptans, potent vasoconstrictor. Max doses apply (e.g., 2mg/day IV, 3mg/day IM, 6mg/week total).
  • Prophylactic: Consider if attacks are frequent (>2-4/month), severe, prolonged, unresponsive to acute treatment, or significantly impacting quality of life.
    • Beta-blockers: Propranolol (start 40mg bd, titrate up to 80-240mg/day). Contraindicated in asthma, caution in depression. Metoprolol, Atenolol also used.
    • Antidepressants: Amitriptyline (start 10-25mg nocte, titrate up to 50-150mg/day). Venlafaxine (SNRI) also an option.
    • Anticonvulsants: Topiramate, Sodium Valproate. Teratogenic potential, side effects.
    • Calcium Channel Blockers: Verapamil (less effective for migraine, more for cluster).
    • Other: Candesartan (ARB), Botulinum toxin injections (for chronic migraine), CGRP monoclonal antibodies (newer, specialist use).
Cluster Headache
  • Acute:
    • High-flow Oxygen: 100% O2 via non-rebreather mask at 12-15 L/min for 15-20 minutes.
    • Sumatriptan: Subcutaneous injection (6mg) is most effective. Intranasal spray (20mg) is an alternative. Oral triptans generally too slow.
  • Prophylactic: Usually initiated by a specialist.
    • Verapamil: (Calcium channel blocker) - First line. Requires ECG monitoring. High doses often needed (e.g., 240-960mg/day).
    • Corticosteroids: Short course (e.g., Prednisolone) can break a cluster cycle.
    • Lithium: Requires monitoring.
    • Other: Topiramate, Galcanezumab (anti-CGRP mAb). Methysergide (rarely used due to fibrosis risk).

Shared Decision Making & Understanding

  • Involve the patient in the management plan. Discuss options, pros, and cons.
  • Check the patient understands the diagnosis, treatment plan, and advice given.

Referral Criteria

  • Emergency Department (ER): If red flag symptoms are present (e.g., thunderclap headache, fever with neck stiffness, focal neurological deficit, significantly altered consciousness).
  • Neurologist:
    • Diagnostic uncertainty.
    • Suspected secondary headache requiring specialist investigation/management (e.g., tumor, GCA).
    • Failure of standard treatments for primary headaches.
    • Consideration for specialist prophylactic medications (e.g., Botox, CGRP mAbs).
    • Management of cluster headache prophylaxis.

Follow-up, Safety Netting & Health Education

  • Arrange a follow-up appointment (e.g., in 4-6 weeks) to review symptoms, assess treatment effectiveness/side effects, review headache diary, and adjust management.
  • Provide clear safety netting advice: When to seek urgent medical attention (e.g., if headache becomes much worse, changes character significantly, develops red flag symptoms, experiences concerning medication side effects).
  • Use the opportunity for opportunistic health education (e.g., mention relevant vaccinations, cancer screening if appropriate for age).

Graph View

Backlinks