Headache

Exam Cram

• Headache is common core presentation to nearly all care providers, including GPs, emergency medicine and general medicine > general surgery

• Differential is broad: containing primary neurological disorders and systemic disorders

• Assessment requires ruling out red flag conditions

• Management: as per underlying cause

Assessment

Background

90% of the information for assessing a headache presentation is in the history. The examination and investigations will commonly be normal and are useful for helping rule out serious pathology. 

History

Red flags

Meningism: neck stiffness, photophobia, phonophobia

Encephalitis: drowsiness, seizures

Features of raised intracranial pressure (raised ICP)

• Worse in morning & at night

• Aggrevated by straining, coughing, sneezing

• O/E- papilloedema

Thunderclap

• Headache that reaches maximum intensity suddenly, under 5 seconds

• Range of causes, in particularly, subarachnoid hemorrhage. 

Examination

• Full neurological examination- focal neurology suggestive of primary neurologic condition

Investigations

• CT- Head

• MRI- Head

• Lumbar Puncture & coagulation profile

• Baseline bloods: FBC, EUC, LFTs, 

• Infective screen: viral PCR, procalcitonin, CRP

Differential Diagnoses

Headache Disorders

• Tension Headache

• Migraine

• Cluster Headache

• Medication Overuse Headache

• IIH (Idiopathic Intracranial Hypertension) 

• Giant Cell Arteritis

• Paroxysmal Hemicrania

Neurological Disorders

• Subarachnoid Haemorrhage

• Haemorrhagic Stroke

• Meningo-encephalitis

• Cerebral Vein Thrombosis 

• Concussion and CTE (Chronic Traumatic Encephalopathy)

Systemic Illness

• Viral infection, e.g. influenza

• Bacterial Sepsis

• Phaeochromocytoma 

Less Likely

• Ischaemic Stroke

• Subdural or extradural haematoma

• Brain tumours

Paroxysmal Hemicrania

• Duration: 2-30 minutes

• Characteristics: unilateral throbbing headache

• Management: indomethacin

Management

Underlying Cause

Treatment focuses around the underlying cause. 

Analgesia

1. Lifestyle: quality sleep, oral hydration, rest, fresh air, UV sunlight, de-stress

2. Paracetamol and/ or NSAIDs: as required, infrequent 

3. IVF if dehydrated

Notes

• Opioids are generally not effective for headaches. 

• Paracetamol & NSAIDs should be used sparingly due to risk of causing Medication Overuse Headache 

• Headache is commonly a sign of dehydration

References and Resources

1. https://bash.org.uk/guidelines/

Written in 2025