The majority of patients who come to their doctor with complaint of headaches will have a diagnosis of migraine, as this is the most common primary headache. For these patients, (as well as most other patients with primary headaches) it is important to ask about the following:

  • Aura: This can potentially limit medication choices. These patients also need to be advised about use of birth control and possible vascular risks.
  • Triggers: Many patients are able to find environmental precipitants for their migraines, with stress and hormonal effects found to be among the most common. 
  • Number of headache days:  The distinction between episodic and chronic headaches can change management options. It’s useful to ask patients to keep a headache diary, noting the severity of headaches, medications they took to treat their headache, and possible patterns or triggers. This can be helpful in later appointments to determine if a new prophylactic medication is working or if a patient is over-medicating with abortive medications.
  • Scores: It can be helpful to use developed questionnaires during follow-up to more objectively assess if a patient is improving. The MIDAS score3 assesses how many days of headache have affected daily living and function, and can be useful in deciding when to start or switch prophylactic medications.

Communication is Key

Perhaps the most important part of examining a headache patient is allowing them to tell their story. Ask open-ended questions so patients feel comfortable telling you what bothers them most. After all, some patients may have headaches daily but only want treatment for their most severe ones. For many, headache is their body’s way of manifesting emotional or psychological pain. This is important to uncover since, if left untreated, patient’s headaches will not improve.

That being said, primary headaches, including migraines, are a neurological disease and patients and their symptoms should not be disregarded, as this will likely lead to non-compliance and frustration on the part of the patient. Overall, treating headaches or other pain conditions requires collaboration and transparency between the patient and provider to come to a diagnosis and accompanying solution.

References

  1. Dodick DW. Diagnosing headache: clinical clues and clinical rules. Adv Stud Med. 2003;3(2):87-92.
  2. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  3. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology. 2001;56(6 Suppl 1):S20-8.