Headache - assessment
Exam Tips
- In OSCEs, classify headache and exclude danger in parallel: characterize phenotype first, then actively screen red flags (sudden onset, neurology, meningism, papilloedema, systemic illness, pregnancy, immunosuppression, malignancy history).
- A normal neurological exam with typical recurrent migraine features supports primary headache; new focal signs or papilloedema should trigger urgent same-day escalation.
- Differentiate behavior during attacks: migraine patients often prefer stillness and darkness, whereas cluster headache patients are typically restless/agitated with ipsilateral autonomic signs.
- Always quantify acute medication days per month to identify medication-overuse headache early.
- Include fundoscopy in your examination script for headache stations; mention papilloedema as a key discriminator for raised intracranial pressure (see Figure from page X in your ophthalmology/neurology revision text).
Definition
Headache assessment is the structured clinical evaluation of a patient aged 16 years or over presenting with head pain, with the dual aim of classifying the headache phenotype (for example migraine, tension-type, or trigeminal autonomic cephalalgia) and excluding dangerous secondary causes. In UK practice, diagnosis is predominantly clinical and is based on a focused history and examination to identify ICHD-consistent features and red flags that require same-day specialist referral or emergency admission.
Pathophysiology
Headache arises when pain-sensitive intracranial or extracranial structures are activated (for example dura, cerebral vessels, cranial nerves, cervical muscles). Primary headaches are neurobiological disorders without another structural disease: migraine involves trigeminovascular activation, release of vasoactive neuropeptides (such as CGRP), and altered brainstem/cortical sensory processing; cluster headache involves hypothalamic-autonomic dysfunction with trigeminal nociceptive activation; tension-type headache is linked to myofascial/pericranial tenderness and central pain modulation changes. Secondary headaches occur when another condition drives nociceptor activation or raised intracranial pressure (for example subarachnoid haemorrhage, meningitis, giant cell arteritis, carbon monoxide exposure, medication-overuse or withdrawal states). See Figure from page X (trigeminovascular pathway and referred pain map) in your neurology core text.
Risk Factors
- Female sex (higher consultation and migraine prevalence)
- Younger age for presentation (consultation rates peak in early adulthood)
- Personal or family history of primary headache (especially migraine)
- Medication overuse (triptans, ergotamines, opioids, or simple analgesics on frequent monthly use)
- Recent withdrawal from caffeine, opioids, alcohol, or oestrogen
- Pregnancy/postpartum state (risk of hypertensive and thrombotic secondary causes)
- Immunocompromise, malignancy history, or systemic inflammatory disease
- Head/neck trauma or Valsalva-triggered onset pattern
- Recreational drug exposure (notably cocaine)
- Household environmental exposure risk (possible carbon monoxide)
Clinical Features
Symptoms
- Onset pattern: sudden thunderclap, progressive, episodic, daily, or unremitting
- Pain phenotype: unilateral/bilateral, orbital/temporal/occipital, throbbing/pressure/sharp, severity and spread
- Migraine-associated features: nausea, vomiting, photophobia, phonophobia, motion sensitivity
- Aura symptoms: fully reversible visual/sensory/speech disturbance developing over minutes and usually resolving within 60 minutes
- Autonomic cranial symptoms (typically ipsilateral in cluster): lacrimation, conjunctival injection, nasal congestion/rhinorrhoea, ptosis, eyelid oedema
- Systemic/neurological warning symptoms: fever, confusion, weakness, visual loss/diplopia, reduced consciousness
- Trigger profile: exertion, cough/sneeze/bending, posture, menstrual relation, stress/fatigue, substance or medication change
- Functional impact clues: preference to lie still (migraine) versus agitation/restlessness during attacks (cluster); minimal activity limitation in tension-type headache
Signs
- Abnormal observations: fever, severe hypertension, hypoxia, tachycardia or bradypnoea
- Altered mental state, meningism, non-blanching rash, reduced GCS
- Focal neurological deficit (cranial nerve palsy, visual field defect, limb weakness, ataxia, gait disturbance)
- Fundoscopic papilloedema or pupillary asymmetry/abnormal reactivity
- Temporal artery tenderness/reduced pulse or scalp tenderness (possible giant cell arteritis)
- Neck stiffness or limited cervical range with meningeal irritation
- Sinus, temporomandibular, dental, ear, or ocular tenderness/signs suggesting local secondary causes
Investigations
Management
Lifestyle Modifications
- Urgently refer/admit if red flags (thunderclap onset, new focal neurology, meningism, papilloedema, altered consciousness, systemic toxicity, suspected giant cell arteritis, pregnancy-related severe headache with hypertension/proteinuria).
- For likely primary headache with normal examination, provide safety-net advice and clear return precautions for neurological change, persistent vomiting, fever, confusion, or sudden worst-ever headache.
- Use a structured headache diary (minimum 8 weeks) to track pattern, triggers, functional impact, and monthly acute medication days.
- Address trigger load: regular sleep, hydration, reduced alcohol excess, caffeine consistency (avoid abrupt withdrawal), stress management, and avoidance of known individual triggers.
- Prevent medication-overuse headache by limiting acute analgesic/triptan use days per month and avoiding routine opioid use.
Pharmacological Treatment
Simple analgesia for acute primary headache symptoms
- Paracetamol 1 g orally every 4-6 hours as needed (max 4 g/24 h)
- Ibuprofen 400 mg orally up to three times daily with food (max 2.4 g/24 h)
- Aspirin 900 mg orally at onset (adult, if appropriate)
Use early in attack. Avoid NSAIDs in active peptic ulcer disease, significant renal impairment, NSAID-sensitive asthma, anticoagulated/high-bleeding-risk states, and in later pregnancy.
Migraine-specific acute therapy
- Sumatriptan 50-100 mg orally at onset; may repeat once after at least 2 hours (max 300 mg/24 h)
- Sumatriptan 6 mg subcutaneously for severe attacks; may repeat after at least 1 hour (max 12 mg/24 h)
Contraindicated in ischaemic heart disease, previous stroke/TIA, peripheral vascular disease, uncontrolled hypertension, and hemiplegic/basilar migraine patterns. Do not combine with ergotamine on same day.
Antiemetic adjunct (especially migraine with nausea/vomiting)
- Metoclopramide 10 mg orally or IM up to three times daily
- Prochlorperazine 3-6 mg buccal every 12 hours or 5-10 mg oral/IM as clinically appropriate
Check extrapyramidal risk, sedation, and QT-prolongation cautions; use shortest effective duration.
Safety/avoidance in assessment phase
- Avoid routine opioids (for example codeine, morphine) for recurrent primary headache
Opioids increase risk of medication-overuse headache, dependence, and chronification; they can also obscure evolving secondary pathology.
Complications
- Missed life-threatening secondary cause (for example subarachnoid haemorrhage, meningitis, intracranial mass lesion)
- Medication-overuse headache with progression to chronic daily headache
- Functional impairment, absenteeism, anxiety/depression, and reduced quality of life
- Vision-threatening morbidity in specific causes (for example giant cell arteritis, idiopathic intracranial hypertension)
- Adverse drug effects (NSAID GI bleed/AKI, triptan cardiovascular events in contraindicated patients, dopamine-antagonist extrapyramidal reactions)
Prognosis
Most patients in primary care have a primary headache disorder and achieve good medium-term control with accurate phenotyping, trigger management, and rational acute therapy. Prognosis is poorer when diagnosis is delayed, red flags are missed, or medication-overuse develops; secondary headache outcomes depend on rapid recognition and treatment of the underlying cause.
Sources & References
✅NICE Guidelines(1)
- Headache - assessment[overview]