History-taking
CPSA · Focused history · Neurological
Headache
Distinguish primary headaches (migraine, tension, cluster) from the sinister secondary causes (SAH, meningitis, raised ICP, GCA). Onset and red flags are everything.
Focused questions
Characterise
- Onset (thunderclap = SAH), duration, frequency, character (throbbing/band/stabbing), site (unilateral/global), timing (worse in the morning = raised ICP)
Associated
- Aura, photophobia, nausea (migraine); neck stiffness, fever, rash (meningitis); visual change, jaw claudication, scalp tenderness (GCA); focal neurology; autonomic (cluster)
Triggers & context
- Triggers (foods, stress, screens), analgesic overuse, recent head injury, immunosuppression, age (>50 new headache = GCA/tumour)
Differentials to screen
Subarachnoid haemorrhageSudden thunderclap “worst ever”, peaks in seconds, neck stiffness
MeningitisFever, neck stiffness, photophobia, non-blanching rash
Giant cell arteritis>50y, temporal tenderness, jaw claudication, visual loss, raised ESR
MigraineRecurrent, throbbing, aura, photophobia, nausea, hours–days
Raised ICP / tumourWorse in the morning/on coughing, vomiting, focal signs, papilloedema
Red flags — exclude these
- Thunderclap onset (SAH)
- Fever + neck stiffness + rash (meningitis)
- New headache >50 with temporal/jaw/visual symptoms (GCA)
- Morning headache with vomiting/focal signs (raised ICP)
- Immunosuppression / anticoagulation
OSCE tips
- “Worst headache ever, sudden” = SAH until a normal CT (± LP for xanthochromia) excludes it.
- New headache over 50 with visual symptoms = start steroids for GCA before the biopsy.
- Ask about analgesic use — medication-overuse headache is common.