Clinical Assessment and Risk Stratification

Headache is the most common neurological condition in the world, with more than 90% of people experiencing headaches at some point in their lives.

90% of headache presentations to the ED are due to primary headaches, usually tension headaches or migraine.

Most patients will be discharged, and many require no investigation beyond a focussed clinical history and examination.

Clinical history

The clinical history is the single most important assessment tool when determining the cause of a headache.

The most significant findings are:

  • Sudden onset – ‘thunderclap’ headache
  • ‘Worst headache’ ever
  • New headache in the elderly
  • Loss of consciousness
  • Headache associated with activity
  • History of neck trauma even mild

If any of these are present, further investigation is required.


The most important features of the clinical examination are:

  • Cognitive state
  • Vital signs
  • Neck movement
  • Pupils – symmetry and fundi
  • Motor function – pronator drift
  • Gait

If any of these are abnormal, further investigation is required.

Following clinical assessment of a patient with headache, most patients will have features that are consistent with one of the primary headache syndromes. However, approximately 10% of patients will have signs or symptoms of headache due to a secondary cause. More information on this topic can be found in the session specifically dealing with secondary headache.

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