Asking right questions leads to better headache diagnosis

Ophthalmologists can monitor the need for further headache evaluation and treatment with several simple question sets and a mnemonic.

Reviewed by Lynn K. Gordon, MD, PhD

Los Angeles-Want to be the office’s hero when it comes to diagnosing patients with headaches?

Here are some simple ways to diagnose headache patients and lead them on the right path to treatment, said Lynn K. Gordon, MD, PhD. 

Neuro-ophthalmologists, as well as general ophthalmologists, can use the mnemonic “SNOOP” to evaluate which headaches may require further evaluation, said Dr. Gordon, Vernon O. Underwood professor of ophthalmology, and senior associate dean, diversity affairs, David Geffen School of Medicine at UCLA, Los Angeles.

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SNOOP stands for:

·      Systemic symptoms

·      Neurologic signs or symptoms

·      Onset is sudden or abrupt

·      Older patients with new or onset headaches

·      Previous headache history: is this the first headache or a change in their previous headaches

If patients have one or more of these signs or symptoms, they will benefit from further evaluation, Dr. Gordon said.

Tracking down the cause


Tracking down the cause

Ophthalmologists also can encourage patients to think more closely about their headaches by asking further questions, such as:

·      Where is the pain?

·      Is it bilateral or unilateral? (“It’s a red flag if it’s always on the same side,” Dr. Gordon said)

·      What’s the severity and duration?

·      What’s the quality of pain? Is it pulsatile, pressure, or stabbing?

·      Are there other symptoms? (this could include nausea, vomiting, and photophobia)

·      Do you have any double vision?

·      During the headache do you want to rest in a quiet, dark space or do you need to stay active or pace around the room?

·      Do you have to miss time from work or other activities due to your headaches?


“You could even have these as a written questionnaire for patients, and hopefully someone else could input the information into your electronic health record,” Dr. Gordon said. This would help save time.

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If a patient’s headaches or headache history triggers red flags, a physician has an obligation to conduct imaging, blood work, or sometimes a spinal tap. If the physician does not feel comfortable delving further into headache diagnosis and treatment, then refer the patient to another specialist with an interest in the area, she advised.

“If you don’t get them to the right doctor, they may not get the right workup and diagnosis, and for sure they won’t get the right treatment,” she said.

Diagnosis is key


Diagnosis is key

One reason that headache diagnosis is so important-aside from the obvious reason of identifying serious health-related problems-is that headache types such as migraines are underdiagnosed, Dr. Gordon said.

“About 75% of patients who come to a doctor because of headaches will have migraines,” she said. “It’s the most commonly underdiagnosed headache type we see.”

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When migraine patients go to the emergency room, only one-third are actually diagnosed with migraine, and fewer than 10% receive migraine-specific therapy.

Dr. Gordon calls those statistics a travesty, but also noted that ophthalmologists who devote extra time to headache care can become heroes in their office when they make the right diagnosis.

To help pinpoint a migraine diagnosis, Dr. Gordon recommended asking three questions:

1) Are you nauseated when you have a headache?

2) Have you missed a day of work or something else you’ve wanted to do in the past 3 months due to a headache?

3) Does light bother you when you have a headache?

Dr. Gordon said patients who experience simpler tension headaches that do not reach the level of a migraine will just take over-the-counter pain relief instead of seeking help from their physician.

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Lynn K. Gordon, MD, PhD


This article was adapted from Dr. Gordon’s presentation at Neuro-Ophthalmology Subspecialty Day during the 2015 meeting of the American Academy of Ophthalmology. Dr. Gordon did not indicate any proprietary interest in the subject matter.

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