Symptoms and Diagnosis: What to Ask Your Patient

Hope O’Brien, MD:
Welcome to NHF Insights, the National Headache Foundation’s podcast, created with the support of our industry partners. We bring you fireside chats with experts on what’s new in migraine and headache care. I’m your host, Dr. Hope O’Brien. I’m a neurologist who’s certified in headache medicine, and I’m also board president of the National Headache Foundation.

This episode is on symptoms and diagnosis and part of our Healthcare Provider Series. Today, we’ll explore how to recognize migraine and other headache disorders. We’ll talk about key symptoms and patterns of headache and finally discuss tools that can simplify diagnosing headache in your clinical practice.

Let me introduce you to today’s guest, Dr. Tanesha Kemble. She’s a family nurse practitioner at Mount Sinai, New York. She’s earned her doctorate from Walden University, and she’s double board-certified by the AANP and ANCC. She’s earned her Advanced Qualification in Headache Medicine (AQH) by the National Headache Foundation, and she treats a wide range of headache disorders including chronic migraine. Welcome Dr. Kemble.

Tanesha Kemble, DNP:
Thank you Dr. O’Brien. Happy to be here today.

Hope O’Brien, MD:
A lot of clinicians actually don’t end up going into headache and so I’m just curious what made you decide to enter into that subspecialty?

Tanesha Kemble, DNP:
It kind of like picked me. I started out my career doing stroke neurology actually. At the neurology clinic we pretty much saw just general neurology patients, but I felt like I gravitated towards patients who had headaches. And I’m thinking it’s because of my emergency room background. When I worked in the emergency room, we did see a lot of headache patients who came in there. There’s lots of lights, there’s lots of noise in the emergency room. And I didn’t feel like they received like the appropriate care that they needed or the environment for them to really experience relief from their headaches. And so, when I was in the outpatient setting and I saw these headache patients came in, we had a few samples there. And they tried it and they came back and they were so appreciative of how much better they felt. And I said, wow, I feel like this is something that I need to do more of and see more of. A year later, I applied to a dedicated headache center, and since then that’s where I’ve been.

Hope O’Brien, MD:
That’s awesome. So, the patients in the emergency room did not scare you?

Tanesha Kemble, DNP:
They did not scare me at all actually. At the time, I wasn’t headache focused, but I think something about them kind of like spoke to me. And so, I think it just continued in the outpatient setting. I just reverted back to that memory that I had with them, and it just feels good making a change.

Hope O’Brien, MD:
So, you have a patient come into your office and they’re complaining of headache. So, what do you think about when a patient comes into you in terms of okay, they have a complaint of headache. What kind of thoughts go into your head in terms of what the diagnosis could be?

Tanesha Kemble, DNP:
We all have headaches, right? We all have stress headaches or tension-type headaches. So, my first thought is this person would not come into the office if it wasn’t having like a huge impact on their life. Because if I have like a little stress headache, then what I tend to do is take a Tylenol or take an Advil and see if that helps and if it goes away. But this patient is seeking medical attention, so my first thought is, okay, this must be something that’s having an impact on their life. And I proceed with asking them a little bit more questions just to determine the type of headache that they’re experiencing.

Hope O’Brien, MD:
That’s a good point. And I will tell you, there are patients who’ve never had headache. I know it’s hard to believe, but there are people who have never had headaches in their life. But the most common type of headache that we’ll see in our clinic is migraine because it tends to impact their day-to-day routine. So, if a patient comes in complaining of a headache and they’re worried because they’re thinking could it be something else. And the most common thing people think about when they see me is like, could I have a brain tumor? So, what do you tell those patients in terms of could this be something really serious?

Tanesha Kemble, DNP:
I would ask them more questions about it, try to figure out what the symptoms they are experiencing. So first and foremost, I would ask them when it started. I would also take into consideration their age, how old they are. Is this a new headache for them? I’d also find out additional features that they’re experiencing. Are they having any sensitivity to light, any sensitivity to sound, any sensitivity to strong smells? In addition to that, I would also find out are they having any nausea? Have they vomited? Is it impacting their ability to function or are they impacted by activity like exercise and things like that?

Hope O’Brien, MD:
So, you’re actually going through the whole criteria for migraine based on the International Classification of Headache Disorders 3rd edition [ICHD-3] that will help guide you towards that diagnosis. And that’s pretty extensive or it can be. But what if you have a few minutes. Are there other tools that providers can use that can key them into the diagnosis pretty quickly?

Tanesha Kemble, DNP:
Well, definitely. There’s a tool. I just ask three specific questions. One of which is are you having any nausea? Are you sensitive to light or sound? Is this having an impact on your ability to function? And if they answer two of those correctly, there’s a high chance that they have a migraine disorder.

Hope O’Brien, MD:
Very nice. So that’s the ID Migraine which is a quick screening tool. And I think most providers probably don’t know about it, but it can really cut down their time in terms of diagnosis.

Tanesha Kemble, DNP:
Absolutely.

Hope O’Brien, MD:
So not only patients worry about what they could have, but there are providers who may also worry about what could I be missing. Are there any tools that can be used to that can help guide providers to help not miss a potentially dangerous headache?

Tanesha Kemble, DNP:
Yes. There’s an acronym that we use. It’s called SNOOP. So, the S is for systemic symptoms and those could be any fevers or weight loss. The N is any other neurological disorders, any type of weaknesses, because we don’t want to miss a stroke or anything else. Is there any like balance issues or ataxia. The first O, it’s for like onset. When did it start? Is it like something that came suddenly? The other O is like looking more at the age of onset. Is it over 50, because migraines typically start in patients who are younger. If you get a headache out of the blue that’s older in age, if you’re 50 or older, then we tend to think that, okay, maybe something else might be going on with this patient. And the P, we look at various things with that. We look at like the quality, is there like any papilledema. And there’s so many other things that we take into consideration. But that acronym kind of helps us to determine if there are any red flags, anything that’s outside of the box that we’re not used to seeing or that does not add up to like the typical migraine headaches or tension headaches or whatever it is that we’re looking at. And so, in cases like those, we tend to do imaging studies, whether it’s a CT scan of the head or an MRI and so on and so forth.

Hope O’Brien, MD:
Absolutely. So, the key is not to miss a potentially secondary headache, something that could potentially be acted upon or treated upon. So, you talked about imaging and so what is your preferred imaging if you have somebody coming in for a headache.

Tanesha Kemble, DNP:
My preferred imaging is an MRI of the brain.

Hope O’Brien, MD:
MRI is great. And what I find is that not everybody deserves an MRI. But as you mentioned, if they have any of the red flags, that’s what we do. And so, any idea of what you tell patients, the percentage of finding anything really bad on an MRI would be or what that likelihood would be?

Tanesha Kemble, DNP:
Well, first and foremost, I do examine them. And if I see anything that’s abnormal then we’ll have the talk about imaging and what it could potentially be based on what I find on the exam. But if it’s a migraine, typically the chances are slim that you’re going to find anything on the MRI. So, after going through their history, and also, I probably didn’t mention this before, if they have like a family history of it and it sounds like it, it talks like it, then I don’t really give a lot of reassurance, but I will try to, I guess, maybe let them know that if it’s a migraine disorder, we typically do not find anything. And a lot of the times it can be diagnosed based on just interviewing the patient, just based on like a history and physical.

Hope O’Brien, MD:
Yeah, absolutely. I think that’s the key point, is to reassure patients that if they do have migraine features and they don’t have any of those red flags, that we can feel comfortable that we can hold off on doing any additional workup like an MRI and diagnose and treat and provide that reassurance.

So now we’re going to move on to some other potential symptoms that can occur with migraine. Let’s talk about aura and the types of aura and how do you differentiate a true aura from maybe symptoms that are not aura.

Tanesha Kemble, DNP:
Not everybody has an aura. For patients who have a typical aura, it can present as a visual aura. They can include like spots. They can include like wavy lines. They can include like colorful things. And it’s important for us to document these auras because patients can have changes later on in life. And if they have changes, that’s also an indication that, okay, maybe we need to do further imaging, like should we include an EEG. Because sometimes we see patients who have seizures. They are preceded by auras as well.

There’s also patients who experience sensory symptoms like numbness and tingling sensation. And sometimes that can even be like confused with patients who are having stroke-like symptoms. But for the sensory symptoms it presents differently. It marches from like an extremity. Say it can march from like your fingertips, and it will go all the way up and to the arm, and then it will go to your mouth and your face as well.

Some folks have these weird smells. I have a patient that they smell cigarette smoke or they smell like some type of chemical before they get their episodes. And those are not as common.

Hope O’Brien, MD:
That is accurate, absolutely. So then let’s talk about maybe other symptoms that patients have. Let’s talk about GI symptoms. So, patients will come in with comorbid let’s say irritable bowel syndrome or may have a lot of nausea with their migraine. How do you address that, especially if patients that’s their primary symptom that they’re coming in with.

Tanesha Kemble, DNP:
I kind of go back into their history as well to see if during childhood they experience any type of like abdominal symptoms, like acute abdominal symptoms. And it may or may not be accompanied by some of these additional migraine features like the sensitivity to light or the sensitivity to sound. But if they have a history of that, that could also be an indication that it may be their migraines coming back later on in life and presenting in that way.

Now, patients who have preexisting GI conditions, like you mentioned, the irritable bowel syndrome, then I collaborate, of course, with the gastrointestinal doctor. And then I make sure that they get evaluated properly. And if based on the GI doctor’s testing and their evaluation, if they don’t find anything else, then after, I guess, interviewing them and finding out other information and how it presents, is it only when they have a migraine, is it sometimes when they don’t have a migraine, and then we also have to take into consideration, like the other features that come with it, because we can’t forget what it states in the diagnostic criteria. We want to also find out if they, in addition to the GI symptoms, are they also still sensitive to light and sound and so on and so forth.

Hope O’Brien, MD:
Absolutely. So, differentiating the difference between abdominal migraine versus the nausea that patients may experience with migraine in and of itself. When you think back to earlier in your career, what would you say has been sort of life changing for you in terms of the confidence that you feel now in making the diagnosis of migraine?

Tanesha Kemble, DNP:
I think the more I saw patients, the more confident I got in making that diagnosis for migraines. And it’s just so fulfilling for me when I have a patient who comes in and they have no clue why they’re getting a headache.

Hope O’Brien, MD:
Is there a particular story that you want to share of someone you’ve impacted based on now your experience and qualification in managing migraine?

Tanesha Kemble, DNP:
Well, yes. I actually saw a patient about a year ago and he came in and he pretty much came and stated that, okay, I was referred to you, I don’t know why I was referred to you, but I went to the hospital because I had this this headache that I’ve had all my life. I already have a neurologist.

To make a long story short, after interviewing him, what I did find out is that he had a different type of migraine. It’s a bit rare. It’s called hemiplegic migraine. And he was admitted to the hospital and like nothing that they gave him was actually helping him. And they also gave him something that was contraindicated. They gave him DHE. And actually, after I explained to him what was going on and I showed him some educational materials, he was so appreciative. And he thanked me because he said, nobody has ever taken the time to really explain to me what these were.

He’s like so many patients and so many other family members have this type of headache and nobody sought medical attention. But he’s like I couldn’t function, I can’t function, and I’m so happy that I met you.

Hope O’Brien, MD:
And that can be life changing.

Tanesha Kemble, DNP:
It was life changing for him. Yes.

Hope O’Brien, MD:
So then how did you learn about AQH and that there was this certification for individuals who were either nurse practitioners or PAs who weren’t physicians to know about there was this certification?

Tanesha Kemble, DNP:
Yeah. So, after the headache, the neurology clinic that I worked at, a year later I applied to a position at a headache center in Manhattan. And while I was there, I attended a conference, one of the Diamond Headache conferences, and I believe it was in Florida. And National Headache Foundation, they actually had a section there, and I visited them and they told me about the certification. And I’m like, yeah, that’s something I’d be interested in. And so, I got the information and I applied to take the exam. And within a matter of months, I didn’t expect that I was going to pass it because I had just started out in the headache world. But after sitting the exam and I passed it, I’m like, oh, wow, I guess headache is me. I get it. And so, I was very excited about that.

Hope O’Brien, MD:
We’re glad you took that exam. Well, thank you for all that you do and for your service.

Tanesha Kemble, DNP:
And thank you, Dr. O’Brien. It’s my pleasure.

Hope O’Brien, MD:
This has been an amazing discussion. Again, thank you, Dr. Kemble for sharing your expertise in recognizing and diagnosing headaches, and for providing tools that can help providers feel more confident and comfortable in their clinical decision making.

Thank you to our listeners for joining us. We hope this conversation helps you make an even greater impact for your patients. And speaking of your patients, we’ve created a companion series. This will help them recognize symptoms, communicate clearly, and come prepared for visits.

Find the full series at headaches.org. Thank you again for listening. Until next time.

This episode of NHF Insights was supported by AbbVie and Pfizer. The content was developed independently by the NHF.

©2026 National Headache Foundation. All Rights Reserved.