SOO and SAMP: Your Study Guide for HEADACHES!

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A woman holding her head in pain with both hands.

SOO and SAMP: Your Study Guide for HEADACHES!

October 16, 2019 | Family Medicine Exam Prep Course | CCFP

Your FMEP Guide to Headaches

You are writing your CCFP exam. You are presented with a patient with a headache. Do you know what to do? What to ask? What your management should be? If you know all the answers – well done. 

If not, keep reading – we have reviewed and summarized an excellent article by the Canadian Family Physicians to help you while you are studying.

Some things to remember about headaches…

  • Rule out secondary headaches when diagnosing primary headache disorders
  • Does the patient have recurrent migraine symptoms and normal neurological exam findings with no red flags on their history? If so, neuroimaging is likely not needed
  • Remember that migraines are the MOST common type of headache – they are underdiagnosed and undertreated (so have this on your differential!)
  • On a SOO, get patients involved in their headache management by asking them to keep headache diaries, adjust lifestyle factors, and manage stress

What information should you gather on a SOO about patients presenting with a headache?

  • Onset, history, duration, and frequency of attacks
  • Location of pain
  • Associated symptoms
  • Precipitating factors
  • Severity and effect on activities (FIFE)
  • Medications tried, results, and side effects
  • Coexistent conditions that could affect treatment plan

On a SAMP, what are some physical exam maneuvers you could consider?

  • Blood pressure
  • Screening neurological exam
  • If indicated, focused neurological exam 
  • Neck examination
  • Examination for temporomandibular disorders (if indicated)

“Doc, is this a migraine?â€

Does the patient tell you that they have at least two of the following symptoms** during the attack?

  • Nausea/vomiting
  • Photosensitivity/phonophobia 
  • Worse with physical activity

** As per CFP article, but not exhaustive.

 If so, diagnose migraine with or without aura.

Does the patient experience headaches on ≥ 15 days/month for > 3 months? Do their headaches meet the above criteria for migraine? Do their attacks respond quickly to migraine medications on≥ 8 days/month?

If so, diagnose chronic migraine.

On a SOO, what’s your management plan?

  • Use acute medications for individual attacks
  • Use prophylactic medications if…
    • attacks are causing considerable disability (despite acute therapy);
    • acute medications are being taken ≥10 days/month (for triptans, ergots, opioids, and combination analgesics) or ≥ 15 days/month (for acetaminophen and NSAIDs); or
    • the patient is having recurrent attacks with prolonged aura, and/or the patient cannot be treated by acute medication due to contraindications
  • Evaluate and treat coexisting disorders

“Doc, is this a tension headache?â€

Do the patient’s attacks include at least two of the following symptoms but no nausea?

  • Bilateral
  • Non-pulsating pain
  • Mild to moderate pain
  • Headache not worsened by movement

If so, diagnose tension-type headache.

Do attacks meet the above criteria and occur on ≥ 15 days/month for > 3 months?

If so, diagnose chronic tension-type headache.

  • Treat with acute medication or with prophylactic medication (if indicated)

“Doc, is this a cluster headache?â€

 Does the patient tell you their attacks meet all of the following criteria?

  • Frequent and severe
  • Brief (< 3 hours)
  • Unilateral (always the same side!)
  • Ipsilateral conjunctival infection, tearing, or restlessness during attacks

If so, diagnose cluster headache (or another trigeminal autonomic cephalalgia).

  • Treat with acute or prophylactic medication depending on frequency of attacks
  • Neurology referral 

“Doc, is this a medication-overuse headache?â€

  • Does the patient experience headaches on ≥ 15 days/month?
  • Does the patient use triptans, ergots, combination analgesics, or opioid-containing medications on ≥10 days/month?
  • Does the patient use acetaminophen or NSAIDs on ≥ 15 days/month?

If any of the above, then diagnose medication-overuse headache.

  • Consider the medication that caused the problem in the first place before stopping the medication cold turkey:
    • Gradual withdrawal of opioids
    • Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs, or triptans
  • Treat remaining severe headache attacks


Written by Maria Veinberg. Reviewed by Dr. Prokubovskaya & Dr. Premji