Headache and Migraine: Red Flags and Treatment

Headache is one of the most common reasons people see a doctor. Most headaches are primary (such as migraine and tension-type headache) and not dangerous. The doctor's key task is to spot the small number of secondary headaches caused by serious conditions, using "red flags".

Red flags for a serious cause

• Thunderclap headache: sudden, severe, peaking within a minute. Think subarachnoid haemorrhage.
• Fever, neck stiffness or rash: meningitis.
• New neurological signs, confusion or seizures.
• New headache in someone over 50, especially with jaw claudication, scalp tenderness or visual symptoms: giant cell arteritis.
• Headache worse on lying down, coughing or straining, or with vomiting or papilloedema: raised intracranial pressure.
• Background risk: cancer, HIV or immunosuppression.
• Pregnancy or the postpartum period: consider pre-eclampsia and venous sinus thrombosis.
• Headache after head injury.
• Progressively worsening or changing pattern.

Migraine

A common, often disabling primary headache, more frequent in women.

Features:

• recurrent attacks lasting 4–72 hours
• often one-sided and throbbing
• moderate to severe
• worse with activity
• accompanied by nausea and/or sensitivity to light and sound

Aura: about a third of patients have an aura, typically visual (zigzag lines or blind spots), developing over 5 minutes or more and lasting up to an hour.

Triggers:

• stress
• lack of sleep
• missed meals
• hormones (menstruation)
• certain foods
• dehydration

Acute treatment

• Simple analgesics (paracetamol, an NSAID such as ibuprofen or aspirin) taken early.
• A triptan (for example sumatriptan), alone or combined with an NSAID.
• An antiemetic for nausea.
• Triptans are avoided in ischaemic heart disease, uncontrolled hypertension and previous stroke.

Prevention

Consider preventive treatment when attacks are frequent or disabling. Options:

• Propranolol (avoid in asthma).
• Amitriptyline.
• Topiramate — teratogenic, and reduces the effect of hormonal contraception.
• Candesartan.
• Newer specialist treatments, such as CGRP-targeted medicines.

Keeping a headache diary helps.

Combined hormonal contraception is contraindicated in migraine with aura, because it increases stroke risk.

Tension-type headache

A bilateral, pressing or "band-like" headache of mild to moderate severity, without nausea and not worsened by activity. Treat with:

• simple analgesics
• stress management
• physical activity

Amitriptyline is used for frequent chronic cases.

Cluster headache

Excruciating, one-sided pain around the eye, lasting 15–180 minutes. Attacks often happen at the same time each day, in "clusters" lasting weeks. Features on the same side:

• a red, watering eye
• a blocked or runny nostril
• a drooping eyelid
• restlessness

It is more common in men and smokers. Treatment:

• Acute: high-flow 100% oxygen and subcutaneous or nasal triptans.
• Prevention: verapamil (with ECG monitoring), under specialist advice.

Medication overuse headache

Frequent use of painkillers can itself cause a daily headache:

• simple analgesics on 15 or more days a month
• triptans, opioids or combination analgesics on 10 or more days a month

Management involves withdrawing the overused medication and starting preventive treatment.

Exam pearls

• Thunderclap headache: urgent CT, then lumbar puncture if the CT is normal and the clinical suspicion remains.
• Patients over 50 with new headache and a raised ESR: start steroids promptly for possible giant cell arteritis, to protect vision.
• Avoid oestrogen-containing contraception in migraine with aura.

For more, see our Exam Night Notes 1.0: Neurology and the neurology chapter of the Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Sudden 'worst ever' headache peaking within a minute. Most important diagnosis?

   1. Subarachnoid haemorrhage
   2. Tension-type headache
   3. Migraine
   4. Sinusitis
   5. Cluster headache
   Show answer

   Answer: A. Subarachnoid haemorrhage
   Thunderclap headache needs urgent CT and, if normal, lumbar puncture.

2. Which contraceptive is contraindicated in migraine with aura?

   1. Combined oral contraceptive
   2. Condoms
   3. Levonorgestrel IUS
   4. Progestogen-only pill
   5. Copper IUD
   Show answer

   Answer: A. Combined oral contraceptive
   Oestrogen-containing contraception increases stroke risk in migraine with aura.

3. Unilateral orbital pain lasting 45 minutes with tearing and a blocked nostril, daily for weeks. Acute treatment?

   1. Ibuprofen only
   2. Oral paracetamol
   3. High-flow 100% oxygen or a subcutaneous/nasal triptan
   4. Amitriptyline
   5. Propranolol
   Show answer

   Answer: C. High-flow 100% oxygen or a subcutaneous/nasal triptan
   This is cluster headache; oxygen and triptans abort attacks.

4. New headache, jaw claudication and a raised ESR in a 72-year-old. Action?

   1. Start steroids promptly to protect vision
   2. Reassure
   3. Give triptan
   4. Wait for biopsy before treatment
   5. Prescribe antibiotics
   Show answer

   Answer: A. Start steroids promptly to protect vision
   Giant cell arteritis risks blindness; start steroids without delay.

5. Which migraine preventive should be avoided in asthma?

   1. Propranolol
   2. Riboflavin
   3. Candesartan
   4. Topiramate
   5. Amitriptyline
   Show answer

   Answer: A. Propranolol
   Non-selective beta-blockers can cause bronchospasm.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.