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.
Examination
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.