It is important to ask a patient presenting with headache about those headaches, including: whether headaches differ or are always the same; the intensity, number and quality of headaches; whether they affect vision; any associated symptoms such as nausea, sensitivity to sound, light, or movement; any known causes or triggers; any family history of headaches; and the patient’s state of health between attacks (anxiety, depression, etc.) (Kernick, 2011). The medications, if any, the patient has been taking are also important, along with dosage and frequency of that medication (Gillies, 2009).
When headaches are the presenting symptom, there are often very few physical signs other than the history of headaches (Welch, 2005). Although this will not likely be present in a scheduled appointment, a patient with sudden severe headache with no known cause should be assessed for signs of stroke, including sudden numbness or weakness in face, arms, or legs; confusion or trouble speaking and understanding speech; sudden vision problems; sudden dizziness, or balance or coordination problems (CDC, 2010).

Headaches can be either primary (i.e., not a symptom of another underlying cause), or secondary (as a result of another disorder) (Kemick, 2011). Primary headaches include migraines, tension headaches, cluster headaches, and “thunderclap” headaches (time from onset to severe pain less than 5 minutes) (Gillies, 2009) . Migraines include headaches not due to other causes and with multiple (at least 5) events with long duration (min. 4 hours to 3 days if untreated); at least 2 of unilateral location, pulsating, moderate to severe intensity, sufficiently severe to impact daily activities; and either nausea/vomiting or avoidance of light and sounds (Kemick, 2011). Cluster headaches are rare in general practice, but have severe or very severe orbital or temporal pain lasting up to 3 hours if untreated; high frequency with only 3 to 48 hours between attacks; and at least one of conjuctival injection and/or lacrimation, nasal congestion, edema of the eyelid, forehead and facial sweating, or restlessness and agitation (Bhola, 2008). Secondary headaches derive from other disorders such as vascular problems, tumors, high intracranial pressure, trauma, infection, or activity-related (sex or exercise) pain (Kemick, 2011). For patients with a history of headaches who have been using analgesics of any sort, headaches may also be caused from dependency on those analgesics (medication overuse headaches) (Gillies, 2009).
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