What Does Your Doctor Need to Know?

Most of us find ourselves distinctly off balance when we attempt to relate our medical histories to an unfamiliar physician. Either we say too much, obscuring the few nuggets of truly important information under an avalanche of largely irrelevant verbiage, or we adopt a tight-lipped, stoical persona wherein information can be extracted by the physician only through a slow, tedious, and painful process; both scenarios tend to lead to frustration for one or both parties and, unfortunately, typically result in management plans that are suboptimal. Appendix 3 is a headache questionnaire, and use of this questionnaire will insure that the clinician will receive the information that he or she requires to make an accurate diagnosis and assist you in developing an appropriate treatment program. The individual elements of that questionnaire will be explained in some detail.

Anchor in Time
As we have emphasized previously, most patients presenting with a chief complaint of headache have migraine, and migraine is a disorder which tends to persist and recur over an extended period of time. It is thus helpful to offer the physician an "anchor in time" as regards to the onset of your particular headache syndrome. When did you first begin experiencing significant headaches? By "significant" we typically mean headaches that were severe enough to force you to cease or greatly restrict your routine activities or headaches that caused you to become physically ill (i.e., nauseated). Did your first severe headache occur years ago, while you were in elementary school, causing you to miss school? Or did you first develop a significant headache yesterday while running to catch a bus? The former obviously would sup*port strongly a diagnosis of migraine, while the latter would raise concern as to the possibility of a secondary headache (see Chapter 2).

Recent Change?
Migraine is exceedingly prevalent, and migraineurs are not exempt from developing superimposed secondary headache. Put another way, migraineurs are just as likely as nonmigraineurs to develop meningitis, ruptured brain aneurysms, brain tumors, or posttraumatic intracranial hematomas. As discussed in Chapter 2, however, the most common reason for a change in the character or frequency of headache in an established migraineur is not the development of a secondary headache; much more frequently the change results from an alteration in the migraine itself, either spontaneously or in response to coexisting analgesic overuse, mood disorder, hormonal change, disrupted sleep, head trauma, concomitant medication, or prolonged stress. If there has been a change in the character or frequency of your headaches, specify when that change occurred, whether there may have been any factors contributing to that change (such as the ones just listed) and precisely how the headaches now are different.

What Is Your Headache Frequency/Severity Profile?
When first asked by a physician "how are your headaches?" new headache patients almost invariably respond "terrible" or some other, more vivid adjective. This is a given; very few patients seek out medical attention for headaches that are "not a problem" What the physician needs to know is (1) how often do you experience headache? and (2) how disabling are your headaches? There are many ways to elicit this information, but one we have found to be useful is first to ask the patient: "Out of the last 30 days, how many days did you have a headache of any degree of severity—mild, moderate, or severe?" Patients who initially may have reported that they experience only three or four headaches per month (thinking that the physician wants only to hear about their most severe attacks) often respond, "Any headache?" Once assured that the physician does indeed wish to know about all headaches, the "three or four headaches a month" often expand to "Well, I have at least some headache every day" Such information is critical to the development of an appropriate management plan; the patient with infrequent episodic migraine, no matter how severe those attacks may be, is quite different from a patient who has daily or near-daily headache, and the treatment prescribed also is quite divergent.

To assess severity, we then ask "out of those [3, 15, 30, whatever] days, on how many of those days were you unable to perform your routine activities because of the headache, whether it involved the entire day or a portion of the day?" These we term "functionally incapacitating headache days" Thus, a headache frequency/severity profile of 15/7 means that over the past month the patient experienced some degree of headache on 15 days and was incapacitated by the headache on seven of those days. This provides a concise and accurate "snapshot" of the patient's headache status during that time and helps immeasurably to shape the management program. Specifically, it enables the physician to answer the watershed question in pharmacologic t reatment of migraine: does this patient require abortive therapy only, or does he or she require a course of prophylactic therapy in addition to appropriate abortive therapy?

To ensure accuracy in your estimation of your current headache frequency/severity profile, it may be particularly helpful to keep a headache diary over the month prior to your initial doctor's appointment. An example of a simple headache diary is provided in Appendix 4.

Duration
Indicate to your physician the duration of your typical headache attack and the range of duration you have experienced in the past. This information can be invaluable in assisting the physician to make an accurate diagnosis. For example, cluster headaches may have migrainous features, but cluster attacks typically last an hour or less ... a much shorter time than usually is observed in migraine. Alternatively, patients who have migraine and at times experience attacks that are prolonged for days ("status migrainosus") will require medications that are designed specifically to treat such prolonged attacks.

Triggers
Some triggers are linked so commonly to migraine that their existence in a given patient may assist the physician in confirming that diagnosis. In addition, viewing the list of triggers provided may get you thinking about components of your life, lifestyle and diet that may be contributing to your headache syndrome.

Menstrually Associated Migraine
If you are female, note for the physician whether or not your headaches seem to be more of a problem during or just around menses. As noted in Chapter 3, the headache attacks of MAM may assume a very different form than migraine attacks that occur during other times of the month, and the treatment prescribed may differ accordingly. If you do have MAM, indicate to the physician whether your MAM simply involves a greater tendency for you to experience your typical migraine attacks or whether the MAM is different, involving a prolonged headache that lasts for days.