History Taking in Neurosurgery : Headache

3 mn read
History Taking in Neurosurgery : Headache

What are the pain sensitive intracranial structures?

Brain itself is pain insensitive. 
The following intracranial structures are pain-sensitive:
  1. Meningeal arteries
  2. Proximal portions of the cerebral arteries
  3. Dura at the base of the brain
  4. Venous sinuses
  5. Cranial nerves 5, 7, 9, and 10, and cervical nerves 1, 2, and 3

What are the mechanisms causing headaches?

  • Distortion or traction of Dura, Venous Sinuses or Blood vessels: 

    • Drainage of CSF in erect posture causes headache, secondary to traction on the venous sinuses when the brain sinks toward the tentorium as it loses CSF flotation
    • Intracranial mass distorts the dura or the arteries at the base of the brain 
    • Distortion due to raised ICP 

  • Distension of a vessel

    • Distension of extracranial and occasionally intracranial arteries is thought to be the cause of pain in migraine (activate the trigeminal nerve terminals in the vessel wall)

  • Inflammation

    • Inflammation in the subarachnoid space can result in headache. Inflammation can be caused by infection, hemorrhage, or chemical irritation
    • Inflammation of vessel wall by autoimmune process. eg Giant cell arteritis

  • Referral of Pain

    • Lesions above the tentorium – referred pain in trigeminal nerve distribution (the forehead or behind the eye) – because the dura in this region is supplied by the trigeminal nerve
    • Lesions in the posterior fossa – 
      • referred pain in the ear and the back of the head – because this part of the dura is supplied by cranial nerves 9 and 10 and the upper three cervical roots
      • refer pain to orbit –  termination of orbital (ophthalmic division) pain nerve fibers in the lowest part of the spinal nucleus of the trigeminal nerve, which also receive termination of the upper cervical pain afferent nerve fibers 
      • referred pain to ear – Irritation of cranial nerves 7, 9, and 10 – because the ear has cutaneous supply from each of these nerves as well as cranial nerve 5.

What are the types of Headaches?

For the purpose of history taking, headaches can be divided into two types:

  • Primary- no identifiable cause on examination or investigation and diagnosis is based on  recognizing a pattern, e.g.
    • Migraine
    • Cluster headache
    • Tension-type headache
  • Secondary – definite identifiable cause on examination or investigation, e.g. 
    • Brain tumors
    • Meningitis
    • Sub-arachnoid hemorrhage 
  • 90% – primary headaches, less than 10% are secondary headaches (Rasmussen 1991)

What are the headache “Red Flags”?

  • Worst Headache ever
  • New onset Headache
  • Onset after age of 50 yrs
  • Change in pattern of headache
  • Worsening headache
  • Sudden onset during exertion, sneezing, coughing
  • Headache with postural variation
  • Headache in setting of malignancy or HIV
  • Headache associated with Neurological symptoms or signs
  • Associated with systemic symptoms – fever, weight loss and chronic cough

What history to take in a patient presenting with Headache?

Exact duration as reported by patient
NEW onset headache or something that has been there since before and has worsened now
Onset ( sudden/ gradual )
Acute onset, severe, first and worst headache, the common possibilities are sub-arachnoid hemorrhage, vascular dissection, pituitary apoplexy
Gradual onset – migraine(mins to days), SDH, GCA(days to months)
verbal rating scale from 0 to 10
Pulsatile or throbbing or hammering (Raised ICP Headaches/ Migraine)
Dull featureless pain (Tension type headache)
Boring sharp- cluster HA
Time of occurrence
Raised ICP headaches – More in morning, May waken the patient at an early hour
Increase in frequency – red flag
Frontal or Holocranial – Raised ICP
Band like – tension headaache
Aggravating factors
Exertion, coughing, sneezing, stooping, and straining at stool
Changes in posture (increases in supine – ↑ICP , increases in upright – low CSF pressure headache)
Relieving factors
Improvement on lying flat – low pressure headache
Associated features
Blurring of Vision – Papilloedema
Diplopia, the commonest cause of which is abducens nerve paresis
Nausea & vomiting – migraine, ↑ICP
Neck stiffness – meningeal process
Changes in consciousness
Focal neurological symptoms


🤞 Don’t miss these high yield posts and exam guidance!

Subscribe to get the Study Material and Exam Guidance posts delivered right into your mailbox.

Leave a Reply

Your email address will not be published.

Explore More Surgery Topics You Like

Best Surgery Books

MRCS Part A: Essential Revision Notes: Book 1
MRCS Part A: Essential Revision Notes: Book 2

MRCS Practice Papers Part A: Paper 1 SBAs

MRCS Practice Papers Part A: Paper 2 EMQs

Rush University Medical Center Review of Surgery

Bailey & Love Companion Guide Mcqs & Emqs In Surgery

SBA MCQs and EMQs for the MRCS Part A Pack: 2

Basic Science for the MRCS: A revision guide for surgical trainees

Oxford Handbook of Clinical Surgery

Get Through MRCS Part A: SBAs

Mrcs Module 2016 Question With Explanations For Mrcs The Best Question Series

EMQs and Data Interpretation Questions in Surgery


DrExam Part B MRCS OSCE Revision Guide: Book 1

DrExam Part B MRCS OSCE Revision Guide: Book 2

OSCEs for the MRCS Part B: A Bailey & Love Revision Guide

Succeeding in the MRCS Part B Exam: Essential revision notes for the OSCE format

Get Through MRCS: Anatomy 2E

Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Harold Ellis

Essential Radiological Anatomy for the MRCS

Surgical Critical Care: For the MRCS OSCE by Mazyar Kanani and Simon Lammy

Surgical Critical Care Vivas by Mazyar Kanani

Mcminn’s Color Atlas of Human Anatomy

Netter’s Atlas of Human Anatomy



Surgery Essence By Pritesh Singh

Surgery Sixer for NBE by Rajamahendran 4th ed (2019)

Bailey & Love Companion Guide Mcqs & Emqs In Surgery

Schwartz’s Principles of Surgery ABSITE and Board Review

Surgery PreTest Self-Assessment and Review, 13th ed


Surgery For PGMEE 13th Edition – 2019 by Amit Ashish


Bailey & Love’s Short Practice of Surgery, 27th Edition

Sabiston’s Textbook of Surgery

Schwartz’s Principles Of Surgery

SRB’S Manual Of Surgery


Operative Techniques in Surgery by Michael W. Mulholland et al

Chassin’s Operative Strategy in General Surgery

Farquharson’s Textbook of Operative General Surgery, 10th Edition


World Surgery Forum – Disclaimer
The information given on this page is for educational purposes only and should not be a substitute for professional medical advice. Do not use this information to diagnose or treat your problem without consulting your doctor. This site respects copyright and does not offer any free ebook downloads. The site and posts may contain amazon links of surgery books and products we love.

WorldSurgeryForum.net has been created by a group of Surgeons and Students, just like you. To create the best possible surgery reference and a teaching site, you can help by sharing some of your expertise, experiences, case reports, surgical images and Surgery Youtube videos. By pooling our collective knowledge and experience, we can make a real difference in how people all over the world are managed for various surgical ailments . Every new article, every case, and every image or video counts.

Check out our Social links for regular updates