Symptoms — We will want to know at what age or when your symptoms started, and how they changed over time. We will ask where the headache is located; what makes it worse or better, the existence of triggers, what physical symptoms besides headache are present (numbness, sensitivity to light touch, weakness, visual changes), changes in the appearance of the eyes or eyelids during attacks, confusion, pain with straining or coughing, changes with posture, changes with sleep, awakening at night with symptoms, seasonal changes, association with any medications you are taking, menstrual association, history of foreign travel, symptoms of infectious disease, exposure to chemicals or fumes, family history of headache, personal or family history of autoimmune disease, aneurysm, or tumor; allergy history; use of caffeine and over-the-counter pain medications; history of head or neck injury, neck pain, areas of tenderness over facial nerves or in neck and shoulders, and anything else you feel may be important. Past history of car sickness, vertigo, convulsions, visual changes, unexplained illnesses. We assess associated conditions — These are often clues to the cause of headaches and can help lead to the best treatment. Of particular interest: insomnia, depression, anxiety, fatigue, digestive disturbances (such as Irritable Bowel Syndrome), neck pain, tempero-mandibular joint (TMJ) pain or dental problems, disorders of the eyes, fibromyalgia, sinusitis and allergic conditions, and hormonal disturbances (such as irregular menses). Personal situation — Are your symptoms causing you to miss days at work, school, or with family or friends? Are there “no way out” personal problems? Are you exercising or working in a posture that is causing problems for you?

Neurological examination — Examination of the eyes, visualization of the back of the eyes and optic nerve, eyelid and facial movement, evaluation of other cranial nerves, muscle strength, tone, and bulk; reflexes; sensory exam and observation of gait and balance where appropriate. General Examination — General health appearance, examination of the hair, skin, nails, blood pressure and pulse, cardiac and pulmonary examination. Evaluation of joints for hypermobility. Headache Examination — headache examination of the neurovascular system: carotid arteries, facial arteries; examination of facial muscles for tenderness or thickening, evaluation of muscles of mastication, neck muscles (weakness, atrophy, hypertrophy, dystonia), evaluation of the spine and jaw for range of motion, restriction, and areas of tenderness. Specific resistance testing (pushing head forward and backward against resistance and determining headache changes) are particularly helpful.

“What kind of headache do you have?”. We will make a diagnosis conforming to the International Headache Society (IHS) diagnostic code. In most cases, we will have a high degree of confidence in the diagnosis, and in a few cases the diagnosis will be provisional pending further tests. These diagnoses allow peer-reviewed research to be applied to your condition. “How are your headaches unique?”. Why is your headache different from others with the same diagnosis? Why is your headache today different from your headache ten years ago, even if the diagnosis hasn’t changed? For further information about our approach to headache diagnosis, please visit the International Headache Society web site at https://ihs-classification.org/en/.