HeadacheDx
Home
Assessment
Algorithm
Guidelines
Clinical Assessment
Complete the history, examination, and investigations to generate a differential diagnosis
History
Exam
Investigations
Scoring
Summary
Onset
How did the headache start?
Thunderclap headache has >40% probability of serious intracranial pathology
Sudden (thunderclap - max intensity within 5 minutes)
Red Flag
Acute onset (minutes to hours)
Gradual onset (hours to days)
Recurrent episodes over weeks/months
Why is this asked?
At what age did headaches first begin?
Primary headache onset after 50 is uncommon; after 65 carries high risk of secondary etiology
Under 20 years
20-50 years
Over 50 years
Red Flag
Over 65 years
Red Flag
Why is this asked?
Duration
How long does each headache episode last (untreated)?
Migraine: 4-72h; Cluster: 15min-3h; TTH: 30min-7days
Seconds to minutes
15 minutes to 3 hours
4 to 72 hours
More than 72 hours or continuous
Why is this asked?
Frequency
How often do headaches occur?
≥15 days/month for >3 months = chronic headache. Consider MOH if using acute meds frequently.
Less than 1 day per month
1-14 days per month
15 or more days per month
Daily or multiple times per day
Why is this asked?
Character
Where is the pain located?
Strictly unilateral (never bilateral) is characteristic of TACs. Migraine is often unilateral but can be bilateral.
Unilateral (one side, always same side)
Unilateral (alternating sides)
Bilateral
Orbital/periorbital
Holocranial (whole head)
Why is this asked?
What is the quality of the pain?
Pulsating quality is one of the POUND criteria for migraine
Pulsating/throbbing
Pressing/tightening (band-like)
Stabbing/sharp
Boring/drilling
Why is this asked?
How severe is the pain (0-10 scale)?
Severity alone does not differentiate primary from secondary headache (BASH 2019)
Mild (1-3)
Moderate (4-6)
Severe (7-9)
Excruciating (10)
Why is this asked?
Aggravating Factors
Is the headache worsened by routine physical activity?
Migraine patients prefer to lie still; cluster patients are restless and pace
Yes - aggravated by or causes avoidance of activity
No - not affected by activity
Restlessness/pacing during attacks
Why is this asked?
Associated Symptoms
Do you experience nausea or vomiting with the headache?
Nausea is one of the most sensitive features for migraine diagnosis
No nausea or vomiting
Nausea without vomiting
Nausea with vomiting
Why is this asked?
Do you experience sensitivity to light or sound?
Light sensitivity is part of the ID Migraine screening tool
Neither
Photophobia (light sensitivity) only
Phonophobia (sound sensitivity) only
Both photophobia and phonophobia
Why is this asked?
Do you experience any of these symptoms on the same side as the headache?
Ipsilateral cranial autonomic features are characteristic of TACs but can occur in 25% of migraine
Tearing/watery eye (lacrimation)
Red/bloodshot eye (conjunctival injection)
Nasal congestion or runny nose
Drooping eyelid (ptosis)
Forehead/facial sweating
Constricted pupil (miosis)
None of the above
Why is this asked?
Do you experience any warning symptoms before or during the headache?
Typical aura develops over ≥5 minutes and lasts 5-60 minutes. Motor weakness suggests hemiplegic migraine - needs specialist referral.
Visual disturbance (flickering lights, zigzag lines, blind spots)
Sensory symptoms (tingling, numbness spreading gradually)
Speech difficulty (dysphasia)
Motor weakness
Red Flag
None
Why is this asked?
Impact
Does the headache limit your daily activities?
Disabling intensity is part of the POUND mnemonic and ID Migraine criteria
No limitation
Some limitation but can continue
Significant limitation - need to stop activities
Completely incapacitating
Why is this asked?
Medications
How many days per month do you take acute headache medications?
MOH criteria: triptans/opioids/ergots ≥10 days/month OR simple analgesics ≥15 days/month for ≥3 months
0-9 days per month
10-14 days per month (triptans/opioids/combination)
Red Flag
15+ days per month (simple analgesics)
Red Flag
Daily use
Red Flag
Why is this asked?
Triggers
Are there identifiable triggers for your headaches?
Predictable triggers (especially menstrual) suggest migraine. Exertional triggers need imaging to exclude posterior fossa lesion.
Menstruation (2 days before to 3 days after period)
Stress or emotional factors
Sleep disturbance (too much or too little)
Alcohol
Specific foods
Weather changes
Cough/Valsalva/exercise
Red Flag
Sexual activity
Red Flag
No identifiable triggers
Why is this asked?
Background
Is there a family history of headaches?
Migraine has strong genetic component - family history supports diagnosis
Yes - migraine in first-degree relative
Yes - other headache type
No family history
Unknown
Why is this asked?
Systemic
Do you have any of these associated systemic symptoms?
Systemic symptoms significantly increase probability of secondary headache
Fever
Red Flag
Weight loss
Red Flag
Night sweats
Red Flag
Jaw claudication (pain with chewing)
Red Flag
Scalp tenderness
Red Flag
Visual disturbance (sudden loss)
Red Flag
Muscle aches (shoulders/hips)
Red Flag
None of the above
Why is this asked?
Trigeminal Neuralgia Features
Do you experience any of these features characteristic of trigeminal neuralgia?
Classic TN: sudden, severe, brief, shock-like recurrent pain in V2/V3 distribution, provoked by innocuous stimuli to trigger zones
Electric shock-like or shooting pain in the face
Pain triggered by light touch to the face (washing, shaving, brushing teeth)
Pain triggered by chewing, talking, or eating
Pain triggered by cold wind or air on the face
Pain strictly in one side of the face (cheek, jaw, teeth, gums, or forehead)
Brief paroxysms of pain lasting seconds to 2 minutes
Refractory period between attacks (pain-free interval)
Pain-free between attacks
None of the above
Why is this asked?
Red Flag Monitor
No red flags detected
Differential Diagnosis
Real-time scoring based on your entries
Migraine
0
Tension-Type
0
Cluster
0
MOH
0
GCA (Temporal Arteritis)
0
Trigeminal Neuralgia
0