Head Injury - History Guide
Author – Dr Euan Strachan Editor -Dr Emily Liu
Last updated 30/04/25
Table of Contents
Introduction
Head injury remains a common reason for presentations to the emergency department in the UK and, akin to trauma as a whole, represents a significant cause of death and morbidity in those aged 1 to 40 years of age. Whilst over 1 million patients will present each year, head injury is by no means a uniform diagnosis, instead incorporating numerous specific pathologies with significant differences in severity across patients.
The Glasgow Coma Scale (GCS) remains the best tool for determining the severity of an individual’s head injury, coupled with a focused history and relevant clinical examination.
Glasgow Coma Scale:
Score | Eyes | Verbal | Motor |
VI | Obeys Commands | ||
V | Alert and orientated | Localises to pain | |
IV | Eyes open spontaneously | Confused speech | Withdraws to pain |
III | Opens eyes to voice | Monosyllabic/ Inappropriate words | Abnormal flexion (decorticate posture) |
II | Opens eyes to pain | Incomprehensible sounds | Abnormal extension (decerebrate posture) |
I | No response | No response | No response |
- Understanding the patient’s GCS will then allow you to provide a score out of 15 (E4 V5 M6). Remember, the minimum score is always 3/15 as the worst possible response in each category will still allocate a score of 1.
- A classification of head injury is then possible, albeit this is an imperfect classification system that serves as a guide only. Regardless, the motor score is the most clinically sensitive measure in neurosurgical patients.
- The individual scores available can be easily remembered with the following mnemonic: E4 – the TV channel; V5 – V is the Roman Numeral for 5; and M6, like the motorway.
Classification of Head Injury Severity
Mild | Moderate | Severe |
GCS 14-15 | GCS 9-13 | GCS 8 or less |
- The presenting GCS informs NICE guidance on pursuing a CT head scan in the context of head injury and helps recognise patients who may need their airway to be secured by an anaesthetist – generally accepted as being those with a GCS of 8 or less (i.e. a severe head injury).
- An intracranial mass lesion (i.e. a haematoma) that requires operative management is seen in approximately 25% of patients with a severe head injury.
Types of Traumatic Brain Injury
| Types of traumatic brain injury | Classic history and presentation |
|---|---|
Extradural haematoma |
|
Subdural haematoma | Acute subdural haematoma
Chronic subdural haematoma
|
Subarachnoid haemorrhage (SAH) |
|
Concussion |
|
Diffuse axonal injury |
|
Presenting Complaint
A full and detailed history is not always possible. Consider a prompt and thorough collateral history for those patients unable to recall events themselves (you should offer this in an OSCE situation regardless).
Details of the Trauma Event:
- Fall from standing (can still be deadly)
- Road traffic collision (if so, was the patient in a car or on a bicycle? What was the speed? etc.)
- Fall down stairs
- Hit by an object, etc.
- This is especially important as trauma can often result from a preceding event or concurrent illness, which will contribute to the patient’s morbidity/mortality if not recognised.
- For example: was there a sudden onset headache to indicate a primary intracranial bleed (e.g. a SAH or haemorrhagic stroke); any viral/infective symptoms causing increased risk of falls; any chest pain or shortness of breath to indicate a primary cardiac event? You can do a systems review at this point.
Associated symptoms
For example: limb shaking, tongue biting, incontinence, post-ictal
- Cervical spine injury can occur in around 8% of head-injured patients and according to Advanced Trauma Life Support Guidance all patients will be triple-immobilised in the trauma setting.
- Any spinal, thoracic, abdominal, pelvic, extremity pain or associated symptoms?
- Specifically ask about any headache?
- SOCRATES the pain
- Ask about number of times
- For example: weakness, sensory changes, speech change, visual changes
What is the trajectory of the patient’s condition?
- Do they have continuing or worsening symptoms e.g. headache, visual disturbance, confusion?
- Is there an evolving focal neurological deficit that lateralises and indicates a likely expanding haematoma e.g. progressive unilateral weakness, visual anopsia, etc
Further Important History
Past Medical and Surgical History
- Relevant conditions may include: previous head injury, epilepsy, bleeding/coagulation disorders, osteoporosis (fracture risk)
Drug history
- Anticoagulants (increase likelihood of intracranial haematoma).
- Seizure medications (altered seizure threshold causing or resulting from injury).
- Drugs that lower blood pressure (e.g. antihypertensives, diuretics, beta-blockers, alpha-blockers) increase risk of falls
- Steroids, antihypertensives/beta-blockers may mask a normal physiological response to trauma.
- Drug allergies.
Social History
- Living situation (house/flat +/- stairs)
- Support network
- Package of care/carers
- Independence with activities of daily living
- Take a thorough alcohol and recreational drugs history – frequency, type, amount.
- The GCS interpretation can be affected by concurrent intoxication, as well as severe injuries being potentially missed in intoxicated patients who do not respond normally to examination.
- Could the trauma be the result of an assault or abuse? Always consider non accidental injury.
- Is there a safeguarding issue?
- Does the patient have carer responsibilities or their own care needs that may suffer?
Clinical Examination
- Lacerations
- Open fractures
- Deformity indicating depressed skull fracture
- External signs that indicate skull base fracture, such as cerebrospinal fluid leak from the ear or nose, ‘panda eyes’, Battle sign, haemotympanum.
- Dirty wounds and/or open fractures should be given Tetanus prophylaxis and cleaned and closed. If a skull base fracture and concurrent pneumocephalus is seen on imaging then additionally give PneumoVax.
- Headache
- Vomiting
- Reduced GCS
- Papilloedema
- Ipsilateral sluggish dilated pupil
- Cranial nerve palsy
- Seizures
- Cushing’s triad (widening pulse pressure, bradycardia, irregular breathing)
- A unilaterally dilated pupil can indicate raised intracranial pressure resulting in trans-tentorial herniation of the temporal lobe, which can cause compression of the oculomotor nerve (cranial nerve III). Compression of CNIII can cause mydriasis, ptosis, and a ‘down-and-out’ ipsilateral eye position.
- Bilaterally fixed and dilated pupils is a late sign and indicates imminent or established brain death.
- Cranial nerves
- Upper and lower limbs
NICE guidelines: indications for CT head
Indications for a CT head in adults within 1 hour:
- A GCS score of 12 or less on initial assessment in the emergency department
- A GCS score of less than 15 at 2 hours after the injury on assessment in the emergency department
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, ‘panda eyes’, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
- Post-traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
A CT Head should be done within 8 hours of injury in those who present with loss of consciousness or amnesia, or within the hour for those presenting more than 8 hours from injury with the following risk factors:
- Age 65 or over
- Any current bleeding or clotting disorders (to include therapeutic anticoagulation)
- Dangerous mechanism of injury (pedestrian versus car, ejected from vehicle, fall from a height of more than 1m or 5 stairs etc)
- More than 30 minutes’ retrograde amnesia of events immediately before the head injury
Delayed presentations
Patients do not always present at the time of their head injury. Post-concussive syndrome can last for several weeks to months following a head injury and represents a constellation of symptoms attributable to ongoing brain dysfunction: headache, confusion, impaired cognition and concentration, low energy, mood alterations, insomnia. These symptoms should all be screened for in patients presenting late to hospital.
Additionally, patients may present late due to complications that arise from an undiagnosed brain injury. This presents a range of differential diagnoses that you should consider and aim your history-taking towards:
- Evolving intracranial haematoma: signs and symptoms of raised intracranial pressure that include: headache, drowsiness, focal neurological deficit, pupillary changes.
- Cerebral oedema: worsening headaches, confusion, raised intracranial pressure. Swelling with contusions worsens in the first 72hrs.
- Hydrocephalus: worsening headaches, confusion, raised intracranial pressure. Is there papilloedema on fundoscopy?
- Pneumocephalus: results typically from a skull base fracture. Worsening headaches and confusion.
- Seizures: note the timing and type of seizure that has occurred, as well as how many seizures they have had as this will inform the role of antiepileptic medication.
- Hyponatraemia: hyponatraemia is a common complication of neurosurgical pathology and may present with similar symptoms of headache and confusion, but if untreated leads to seizures and coma.
- Hypopituitarism: less common but results from trauma involving the pituitary fossa, gland or stalk. Non-specific endocrine dysfunction and may exacerbate hyponatraemia secondary to brain injury. These patients need steroid resuscitation. Ask questions that will indicate any dysfunction within the hypothalamic-pituitary-adrenal axis e.g. fatigue, cold intolerance, weight loss/gain etc.
- Dural venous sinus thrombosis: particularly due to fractures that overlie the major venous sinuses. Signs/symptoms may include severe headaches, focal neurological impairment, papilloedema, visual loss, seizures, etc.
Never forget non-accidental injury (NAI), especially in paediatric patients. A delayed presentation may be a first opportunity to intervene.
MLA Tip 💡
Always screen for red flag signs and symptoms that may be indications for an urgent CT head.
- https://www.nice.org.uk/guidance/ng232/chapter/Context (last accessed 9th March 2025).
- https://www.nice.org.uk/guidance/ng232/chapter/recommendations (last accessed 9th March 2025).
- M.S. Greenberg. Handbook of Neurosurgery 9th Edition. 2020. Thieme Medical Publishers, Inc.
- Postconcussive syndrome. https://www.ncbi.nlm.nih.gov/books/NBK534786/ (last accessed 9th March 2025).