How to Take a Headache History: Strategies

Deborah I. Friedman, MD, MPH, FAHS


March 15, 2019

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Most headache disorders encountered in practice have no outward signs or laboratory findings—the patient's history remains the key to making the correct diagnosis. The headache history is similar to other types of history-gathering in medicine, but there are strategies and pointed questions that can help the physician arrive at a correct diagnosis. The differential diagnosis considers the age at onset, duration of symptoms, character of the pain and presence/absence of associated symptoms, tempo of an individual attack and/or overall headache experience, previous headache history, treatments tried, family history, and other aspects of a traditional medical history.

The American Migraine Communication Study found that patients were more satisfied with their initial interview when they were asked open-ended questions, particularly those regarding the impact of migraine on their lives.[1] Nonetheless, certain data can best be ascertained by short-answer questions, which give the interviewer an idea of which headache type might be present. It's important to keep in mind that a person may have multiple headache types, and it can take more than one session to get a true picture of the patient's entire headache experience.

The Right Tools

A headache intake form (either paper or electronic), which is sent to the patient in advance of his or her appointment, is an extremely helpful tool to prepare the patient for questions that will be asked during the visit. It also helps the patient and the interviewer organize their approach to the interview. There are many examples, and mine can be found here.

It's useful to have the patient start with a focused chief complaint, limited to 10 words, because it provides the principal perspective of what is most important to him or her. Unless patients have cognitive impairment or are nonverbal, it is best for them to recount their own history; this may require asking accompanying people to hold their comments or even leave the exam room temporarily. Adult assistance is needed to assess young children, but asking children to draw a picture of their headache can be enlightening.[2]

We then move to the beginning of the patient's headache journey with a chronological recounting of symptoms and events. For each headache type, the interviewer should ask about any premonitory or aura symptoms, the location of the pain (which may also include the neck, face, or upper back/shoulders), how the pain develops, a description of its character (eg, throbbing, aching, pressure, stabbing), pain severity, and duration of an attack.

The associated symptoms, or lack thereof, are important in categorizing the headache and encompass four major subtypes: migrainous, neurologic, trigeminal autonomic/cluster headache-like, or systemic. A checklist of symptoms helps the patient identify her symptoms and also helps the interviewer's thoroughness.


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