The single most important part of the headache evaluation is the case history,  An accurate differential diagnosis can be made 90% of the time from case history alone, if you know what to look for.  The primary goal of the first encounter is to rule out secondary headache. Once that is complete, a patient can be brought back for further testing for possible ocular or visual etiology.

Eye doctors must approach headache efficiently, with a detailed history and comprehensive ocular examination to rule out the malignant headaches that may blind or even kill the patient.  Identifying potential red flags associated with secondary headache is essential in learning a patient’s history.  Red flags can include: First or worst headache ever, acute or sudden onset, onset after 50 years old, worsening headache, headache associated with systemic symptoms, changes in pain patterns, always in the same location, pain that awakens the patient from sleep and neurological symptoms and signs.

Patient questionnaires are invaluable in diagnosing a cause of headache using the PQRST criteria.

P – Provocation/palliation. Provocation is factors that bring on the headache such as relative hypoglycemia, bright lights, loud noises or various odors like cologne and gasoline. Palliative is any treatment that improves the head pain.

Q – Quality/quantity. What is the character of the pain? Is it a pounding, throbbing (vascular), tightness (tension) or a pain behind the eyes (sinus headache)?

R – Region/radiation. Pain on one side or one area of the head.

S – Severity scale. On a scale from 1 to 10, with 10 being the most severe, how would you grade your pain?

T – Temporal/time. When did the pain start and at what age? How often does the patient get these headaches? The frequency of the headaches guides the treatment protocol.

It is easy to differentiate a need for glasses vs. a medical origin. Nearsighted patients do not usually complain of headache unless they are over-corrected. Uncorrected or under-corrected farsighted will complain of peri-ocular pain when reading or doing near tasks.  Patients with astigmatism, when uncorrected, will have visual difficulties at all distances, and the strain associated with trying to see clearly by squinting will tend to be more constant.

The brain isn’t a pain sensitive structure.  What is painful is the nerve and blood vessels that run through the brain and head. If there is an abnormality with a blood vessel or nerve, it tends to send a more localized pain.

The type of headache most commonly seen is tension headache. Patients will complain of a band-like sensation across the forehead, and the pain can switch sides.

When taking a patient’s history, we look for a usual age of onset between the teens to late 30s. We are suspicious of headaches beginning earlier or later in life, as it may represent disease.

A sinus headache frequently triggers pain or pressure around the eyes, it is not uncommon for sufferers to contact an eye care professional.

Sinus-related headaches are easily diagnosed in the office following a three-step sinus evaluation, consisting of articulation of facial bones, percussion and transillumination of the sinuses.

Approximately 37 million Americans suffer from migraine headaches, and women are affected two to three times more often than men. Of those with migraines, 90% have a family history.   Migraine headaches are often brought on by triggers such as chocolate, red wine, cheese, cologne and bright lights.  Migraine sufferers often will have nausea and visual symptoms such as scintillating vision.

In general, Patients are good historians and know if something is off, and we as practitioners should trust them to help us figure out the cause.