Headache Questions to Ask Patient
Twenty history-taking questions for a patient presenting with headache, in the order a consultation usually runs: onset and speed of onset, site and character of the pain, duration and frequency, warning symptoms, associated features, triggers, red flag screening, head injury, everything they have taken for it, and the effect on their work and daily life. Written for clinicians and students taking a headache history.
The questions
Open any question for the note
Tell me about the headache in your own words, starting with when it began.
Why ask it
An open start gets the patient's own framing before your categories are imposed on it. Note whether they date the problem to a single event, an illness, a new job, a bereavement, since that anchor often does not appear again once the questions become closed.
Did the pain come on gradually, or reach its worst within a minute or two?
Why ask it
Pain that reaches maximum intensity almost instantly needs urgent assessment for subarachnoid hemorrhage and other vascular causes, whatever the patient looks like now. Ask them to place it in seconds or minutes rather than accepting the word sudden.
Is this like headaches you have had before, or is this one different?
Why ask it
A long-standing pattern points toward a primary headache. A first ever headache, or a familiar headache that has changed in character, moves the assessment toward secondary causes and is the single most useful discriminator in the history.
Where is the pain, and does it stay in the same place each time?
Why ask it
Side-locked pain in every attack is worth flagging for imaging. Migraine often changes sides between attacks, cluster headache stays around one eye, and pain that spreads from the neck upwards suggests a cervical contribution.
What does the pain feel like: throbbing, pressure, stabbing, burning?
Why ask it
Patients often reach for the word they have heard rather than the sensation, so offer options and let them reject them. Throbbing that worsens with movement suggests migraine, a tight band suggests tension type, brief electric stabs suggest a different group altogether.
How bad is it at its worst, on a scale of zero to ten, and how bad is it right now?
Why ask it
Two figures are more useful than one, because the gap shows where in the attack you are meeting them. A stated ten in a patient who is sitting comfortably and talking normally is worth exploring rather than recording without comment.
How long does an attack last if you take nothing for it?
Why ask it
The untreated duration is the diagnostic figure, and patients will otherwise report how long it lasts after painkillers. Attacks of four hours to three days fit migraine, fifteen to 180 minutes fit cluster headache, seconds to minutes fit the short-lasting group.
How many days in a typical month do you have any headache at all?
Why ask it
Ask for headache days rather than attacks, because that is the number that separates episodic from chronic and the number that will show whether treatment is working. Fifteen or more days a month over three months changes the management plan.
Do you get any warning in the half hour before it starts, such as changes in your vision, numbness, or trouble finding words?
Why ask it
Aura typically builds over five to twenty minutes and resolves within an hour, which distinguishes it from a stroke and from the vague premonitory tiredness many patients also describe. Motor weakness is not typical aura and needs separate assessment.
What else happens along with the pain: nausea, vomiting, sensitivity to light or noise, a watering eye or blocked nostril on one side?
Why ask it
Nausea with light and noise sensitivity supports migraine. One-sided tearing, redness, nasal blockage or a drooping lid points to the trigeminal autonomic group, and patients rarely volunteer these because they do not connect them to a headache.
What makes it worse once it has started, including coughing, bending forward, or lying down?
Why ask it
Routine movement worsening the pain supports migraine. Pain that is clearly worse when lying flat, or worse on coughing and straining, raises the question of raised intracranial pressure, and pain worse when upright suggests low pressure instead.
Is there anything that reliably brings one on?
Why ask it
Insist on reliably. Most reported triggers do not reproduce on testing, and skipped meals, poor sleep and dehydration are far more consistent culprits than any single food. A craving before an attack is often the early headache rather than its cause.
Does anyone in your family get headaches like these?
Why ask it
A first-degree relative with migraine supports the diagnosis, but many families call the same attacks sinus headaches or bad heads. Ask what the relative did during an attack rather than what they called it.
Does the headache wake you at night, or is it at its worst when you first get up?
Why ask it
Waking with pain has several plausible explanations, including cluster headache, sleep apnea, bruxism and medication wearing off overnight. Consistently worst on waking and easing through the morning is one of the patterns that prompts imaging.
Has anything about your headaches changed in the past few months?
Why ask it
Change is more significant than severity. A new pattern, a new site, more frequent attacks or a different response to the usual painkiller are all worth taking seriously, particularly over the age of fifty.
Have you had any fever, a stiff neck, a rash, weight loss, or pain in your jaw when chewing?
Why ask it
A screening question for causes that are treatable and time-critical, including meningitis and giant cell arteritis. Jaw pain on chewing with scalp tenderness in an older patient should not wait for the end of the consultation.
Have you noticed any weakness, clumsiness, seizures, or changes other people have remarked on?
Why ask it
Asking what other people have noticed catches personality and cognitive change that patients do not report themselves. Any new focal deficit alongside headache moves this from a history to an urgent examination.
Have you had a head injury, or any procedure involving your spine, in the past few weeks?
Why ask it
Both are easy to miss because the patient does not connect them. A fall with delayed headache raises the question of a subdural collection, particularly in older patients or those on anticoagulants, and a recent lumbar puncture or epidural suggests low pressure headache.
What have you taken for the pain, at what dose, how many days a week, and what else do you take regularly?
Why ask it
Frequency matters more than the drug. Regular use on ten or more days a month of triptans, opioids or combination painkillers, or fifteen or more of simple painkillers, is enough to sustain the headache being treated. Also ask about hormonal contraception, nitrates and over-the-counter remedies.
What has the headache stopped you doing, and what would you most want treatment to give back?
Why ask it
Turns severity into something measurable: missed shifts, cancelled plans, a hobby dropped. It also surfaces the mismatch worth naming early, since a patient hoping to be pain-free and a clinician aiming to halve attack frequency will otherwise both consider the plan a failure.
Taking a headache history
Practical guidance for the conversation itself
Running the consultation
Two minutes of open listening first
Let the patient describe the headache uninterrupted before you start narrowing. Most of the diagnostic content arrives in that opening account, and interrupting early tends to produce yes and no answers for the rest of the visit.
Ask about the worst attack and the typical attack separately
Patients answer about whichever is most vivid, usually the worst. Separating the two prevents a single severe episode from being recorded as the pattern, and it also gives you the untreated duration you need for classification.
Count days, not attacks
Headache days per month is the figure that classifies the problem and the figure that shows whether treatment helped. Attack counts are unreliable once attacks run into each other.
Ask about painkiller frequency without judgment
Patients under-report analgesic use when they sense disapproval, and this is the detail most likely to explain a headache that will not settle. Ask how many days a week they take something, not whether they take too much.
Features that change the plan
- Maximum intensity within a minute or two of onset, at any age.
- First or worst headache of the patient's life, especially over the age of fifty.
- New focal neurological signs, seizure, confusion, or personality change reported by someone else.
- Fever with neck stiffness or a rash.
- Pain clearly worse lying flat, on coughing or straining, or on waking, particularly with vomiting.
- Jaw pain on chewing, scalp tenderness or visual loss in a patient over fifty.
- Headache in pregnancy or the postpartum period, in immunosuppression, or in active cancer.
- Recent head injury, especially with anticoagulation, or a recent lumbar puncture or epidural.
Common pitfalls
Accepting the patient's own label
Sinus headache, tension headache and migraine are used interchangeably by patients and by previous clinicians. Take the description apart and reclassify it rather than inheriting the label in the notes.
Recording treated duration
If the patient takes a triptan within twenty minutes every time, they cannot tell you how long an untreated attack lasts. Ask what happened before they had the medication, or about the one occasion they had none with them.
Stopping at the primary diagnosis
A patient with a long history of migraine can also develop a secondary headache. The question about what has changed recently is the one that catches it, and it is the one most often skipped in a follow-up appointment.
Leaving out the impact
Without days lost from work, cancelled plans and effect on mood, there is no baseline to measure treatment against and no case for a preventive if one is needed later.
Closing the visit
- Ask the patient to keep a simple diary: date, duration, what they took, and whether it worked. Four weeks of that is worth more than any further questioning.
- Summarize the pattern back to them in one or two sentences and ask whether it sounds right. Corrections at this point are common and useful.
- Say plainly what would make you want to see them sooner, in the patient's own terms rather than as a list of signs.
- Record the untreated duration, headache days per month and analgesic days per month as figures, so the next clinician has something to compare against.