Headache accounts for 4.4% of consultations in primary care (6.4% females and 2.5% males). Unless a correct diagnosis is made, it is not possible to provide the most effective treatment. For most medical ailments the suspected diagnosis can be confirmed with tests, but no diagnostic test can confirm the most common headaches, such as migraine or tension-type headache.

This means that unless the headache is obvious, diagnosis is largely based on the history. In addition, the examination of people with primary headaches is essentially normal. Consequently, the diagnosis is not always easy, particularly if several headaches coexist, confusing both patient and doctor.

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Headaches Summary

Headaches are a common cause of pain in the general population. There are different forms of headaches and treatment options may vary depending on the type of headache. Medication overuse headache is an important entity and should be consider in all patients with chronic headaches. Interventional treatments can be used in certain forms of headaches including botox injections for migraines.

Classification Of Headache By International Headache Society

Primary headaches

  • Migraine
  • Tension-type headache
  • Cluster headache and other trigeminal autonomic cephalalgias
  • Other primary headaches

Secondary headaches

  • Headache attributed to head and/or neck trauma
  • Headache attributed to cranial or cervical vascular disorder
  • Headache attributed to non-vascular intracranial disorder
  • Headache attributed to a substance or its withdrawal
  • Headache attributed to infection
  • Headache attributed to disorder of homoeostasis
  • Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
  • Headache attributed to psychiatric disorder


Migraine is a common disabling primary headache disorder. Epidemiological studies have documented its high prevalence and high socio-economic and personal impacts. Migraine can be divided into two major sub-types:

Migraine without aura is a clinical syndrome characterised by headache with specific features and associated symptoms. Migraine without aura is the commonest subtype of migraine. It has a higher average attack frequency and is usually more disabling than Migraine with aura. Migraine without aura often has a strict menstrual relationship. Migraine headache is usually frontotemporal.


A. At least 5 attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C. Headache has at least two of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia

E. Not attributed to another disorder

When attacks occur on ≥15 days/month for >3 months, it is referred to as chronic migraine, provided there is no history of medication overuse.

Migraine headache is commonly bilateral in young children; an adult pattern of unilateral pain usually emerges in late adolescence or early adult life.

Migraine with aura is primarily characterised by the focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a premonitory phase, occurring hours or days before the headache, and a headache resolution phase. Premonitory and resolution symptoms include hyperactivity, hypoactivity, depression, craving for particular foods, repetitive yawning and other less typical symptoms reported by some patients.

Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, headache lacks migrainous features or is completely absent.

Aggravating factors

Psychosocial stress, frequent intake of alcoholic beverages, other environmental factors.

Tension- Type Headache

This is the most common type of primary headache: its lifetime prevalence in the general population ranges in different studies from 30 to 78%.

Diagnostic criteria for episodic tension type headache

A. At least 10 episodes occurring in <1 day a month on average (<12 days a year) and fulfilling criteria B-D (infrequent    episodic tension-type headache) or at least 10 episodes occurring on >1 but <15 days per month for at least three months            (>12 and <180 days per year) and fulfilling criteria B-D (frequent episodic tension-type headache)
B. Headache attacks lasting from 30 minutes to seven days
C. Headache has at least two of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia

E. Not attributed to another disorder

Chronic tension-type headache is less common, with a one-year prevalence of 2 3%. It typically evolves over time from episodic tension-type headache. It occurs, by definition, on more than 15 days a month, and may be daily.

The pain is typically bilateral, characteristically pressing or tightening in quality and mild to moderate in intensity. Nausea is not present and the headache is not aggravated by physical activity. There may be associated pericranial tenderness, sensitivity to light or sensitivity to noise.

The exact mechanism of tension-type headache is not known. Tension-type headache may be stress-related or associated with functional or structural cervical or cranial musculoskeletal abnormality.

Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TACs) are rare and are characterised by attacks of severe unilateral pain in a trigeminal distribution. They are associated with prominent ipsilateral cranial autonomic features. Cluster headache (CH) is the most common TAC (estimated prevalence 1 in 1,000). Paroxysmal hemicrania (PH) is probably under-recognised (estimated prevalence 1 in 50,000). Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are very rare.

Cluster Headaches

Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack.

Age at onset is usually 20-40 years. For unknown reasons prevalence is 3-4 times higher in men than in women.

Diagnostic criteria

A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by at least one of the following:

  • Ipsilateral conjunctival injection and/or lacrimation
  • Ipsilateral nasal congestion and/or rhinorrhoea
  • Ipsilateral eyelid oedema
  • Ipsilateral forehead and facial sweating
  • Ipsilateral miosis and/or ptosis
  • Sense of restlessness or agitation

D. Attacks have a frequency from one every other day to 8 per day
E. Not attributed to another disorder

Acute attacks involve activation of the posterior hypothalamic grey matter. Cluster headache may be inherited (autosomal dominant) in about 5% of cases. Attacks usually occur in series (cluster periods) lasting for weeks or months separated by remission periods usually lasting months or years. However, about 10-15% of patients have chronic symptoms without remissions.

During a cluster period, and in the chronic subtype, attacks occur regularly and may be provoked by alcohol, histamine or nitroglycerine. Pain is maximal orbitally, supraorbitally, temporally or in any combination of these sites, but may spread to other regions of the head. Pain almost invariably recurs on the same side during an individual cluster period. During the worst attacks, the intensity of pain is excruciating. Patients are usually unable to lie down and characteristically pace the floor.

Paroxysmal Hemicrania

Paroxysmal hemicrania has similar characteristics to cluster headache, but attacks are shorter (2-45 minutes), more frequent (up to 40 per day) and it is more common in women. The majority of patients have the chronic rather than episodic form. Most attacks are spontaneous but 10% can be precipitated mechanically by bending or rotating the head. Diagnosis using ICHD-II criteria consists of the presence of a complete response to indomethacin and ipsilateral autonomic features during an attack.


SUNCT has similar characteristics to cluster headache and paroxysmal hemicrania. Attacks are shorter (2-250 seconds) and more frequent (up to 30 per hour). They occur as single stabs, groups of stabs or in an overlapping fashion (“sawtooth”). Bouts may last one to three hours at a time. Conjunctival injection and/or tearing are a requirement for the diagnosis. Attacks may be spontaneous or triggered by trigeminal (eg touching face) or extra-trigeminal (eg exercise) manoeuvres. Relapses and remissions are erratic.

Secondary Headache

Secondary headache (ie headache caused by another condition) should be considered in patients presenting with new onset headache or headache that differs from their usual headache. Observational studies have highlighted the following warning signs or red flags for potential secondary headache which requires further investigation:

  • New onset or change in headache in patients who are aged over 50
  • Thunderclap: rapid time to peak headache intensity (seconds to 5 mins)
  • Focal neurological symptoms ( limb weakness, aura <5 min or >1 hr)
  • Non-focal neurological symptoms (cognitive disturbance)
  • Change in headache frequency, characteristics or associated symptoms
  • Abnormal neurological examination
  • Headache that changes with posture
  • Headache wakening the patient up (NB migraine is the most frequent cause morning headache)
  • Headache precipitated by physical exertion or valsalva manoeuvre (eg coughing, laughing, straining)
  • Patients with risk factors for cerebral venous sinus thrombosis
  • Jaw claudication or visual disturbance
  • Neck stiffness
  • Fever
  • New onset headache in a patient with a history of human immunodeficiency virus (HIV) infection
  • New onset headache in a patient with a history of cancer

Cervicogenic Headache

The contribution of cervical spine disorders to migraine and tension-type headache is poorly understood. Fourteen to 18% of chronic headaches are cervicogenic in origin, ie result from a musculoskeletal dysfunction in the cervical spine. Cervicogenic headache consists of a unilateral or bilateral pain localised to the neck and occipital region which may project to regions on the head and/or face Pain may be precipitated or aggravated by particular neck movements or sustained neck postures and is associated with altered neck posture, movement, muscle tone contour and/or musclemtenderness. Manual examination identifying articular mobility, muscle extensibility and range of motion, in the form of flexion and extension may assist diagnosis. A headache may also be cervicogenic in origin if there is clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine.

Medication Overuse Headache

Medication overuse headache (MOH) is defined as headache which is present for 15 days or more per month and which has developed or worsened while taking regular symptomatic medication. Medication overuse headache is reported in migraine, tension-type headache, hemicranias continua, new daily persistent headache, cluster headache and SUNCT. Patients with cluster headache and SUNCT who develop MOH usually have a personal or family history of migraine.

ICHD-II criteria suggest medication overuse headache should be considered with use on ten days per month for triptans, ergots, opioids or combination analgesics and on 15 days per month for simple analgesics. Patients with a history of migraine headache who frequently use pain medications for non-headache pain are at increased risk of developing chronic daily headache. Patients who overuse medications are more likely to develop chronic daily headache. The risk depends on which medication is being overused (opioid OR 4.4; triptan OR 3.7; ergot OR 2.9; analgesics OR 2.7).

Management Of Headaches

Treatment of acute migraine

  • Options include aspirin, ibuprofen and paracetamol
  • Oral triptans are recommended if simple analgesics fail.
  • If one triptan deos not work, an alternative triptan should be tried.
  • Triptans should be taken at, or soon after, the onset of the headache phase of a migraine attack.
  • Nasal zolmitriptan or subcutaneous sumatriptan should be considered in severe migraine or where vomiting precludes oral route or where oral triptans have been ineffective.
  • Ergotamine is not recommended for patients with acute migraine.

Pharmacological prophylaxis for migraine

  • Beta blockers
  • Tricyclics
  • Topiramate
  • Valproate
  • Pizotifen

Treatment of tension-type headache

  • Aspirin and paracetamol are recommended for acute treatment in patients with tensiontype headache.

Pharmacological prophylaxis for tension-type headaches

  • Gabapentin
  • Tricyclics

 Acute treatment of cluster headaches

  • Triptans
  • 100% oxygen
  • Lidocaine 10% nasal drops

Pharmacological prophylaxis for cluster headaches

  • Verapamil
  • Lithium

Management Of Medication Over Use Headache

  • Patients with medication overuse headache caused by simple analgesics or triptans should be advised to abruptly withdraw the overused medication.
  • Patients with medication overuse headache caused by opioids and opioid-containing analgesics should be considered for gradual withdrawal of the overused medications.
  • In patients with medication overuse headache, topiramate may be considered in order to reduce the total number of headache days.
  • Amitriptyline and sodium valproate may be used to reduce headache during abrupt withdrawal in patients with medication overuse headache.

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Dr Murli Krishna

Consultant Pain Medicine