Headache - Clicical Approach




  • Have underlying cause
  • Medication overuse, arteritis, ↑ICP, infection.


High risk (investigate further)

  • Sudden-onset headache (max intensity in 1 min)
  • Worsening headache with fever
  • New-onset neurological deficit
  • New-onset cognitive dysfunction
  • Change in personality
  • Impaired level of consciousness
  • Recent (3 months) head trauma
  • Headache triggered by cough, valsalva
  • Headache triggered by exercise
  • Orthostatic headache (changes with posture)
  • Symptoms suggestive of giant cell arteritis
  • Symptoms and signs of acute narrow-angle glaucoma
  • Substantial change in the characteristics of their headache.

Consider referral

  • Compromised immunity
  • Hx malignancy
  • Vomiting without other obvious cause.


  • Subarachnoid
  • Meningitis
  • ↑ICP (E.g SOL - neuros signs, papilloedema)
  • Venous thrombosis (papilloedema)
  • Glaucoma - headache, blurred vision, vomiting, dusky cornea (recent halos), semi dilated pupil (constricted in cluster)
  • Cluster bouts
  • Temporal arteritis - jaw claudication, new headache, myalgia, ±tender temporal art, ↑ESR, ±PMR ("roll" out of bed).
  • Optic neuritis may present with retro-orbital pain with eye movement.

Headache feature Tension-type headache Migraine (with or without aura) Cluster headache
Pain location 1 Bilateral Unilateral or bilateral Unilateral (around the eye, above the eye and along the side of the head/face)
Pain quality Pressing / tightening (non-pulsating) Pulsating (throbbing or banging in young people aged 12–17 years) Variable (can be sharp, boring, burning, throbbing or tightening)
Pain intensity Mild or moderate Moderate or severe Severe or very severe
Effect on activities Not aggravated by routine activities of daily living Aggravated by, or causes avoidance of, routine activities of daily living Restlessness or agitation
Other symptoms None Unusual sensitivity to light and/or sound or nausea and/or vomiting Aura Symptoms can occur with or without headache and:
  • are fully reversible
  • develop over at least 5 minutes
  • last 5−60 minutes
Typical aura symptoms include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory symptoms such as numbness and/or pins and needles; and/or speech disturbance.
On the same side as the headache:
  • red and/or watery eye
  • nasal congestion and/or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil and/or drooping eyelid
Duration of headache 30 minutes–continuous 4–72 hours in adults 1–72 hours in young people aged 12–17 years 15–180 minutes
Frequency of headache < 15 days per month ≥ 15 days per month for more than 3 months < 15 days per month ≥ 15 days per month for more than 3 months 1 every other day to 8 per day, with remission> 1 month 1 every other day to 8 per day, with a continuous remission4<1 month in a 12-month period
Diagnosis Episodic tension-type headache Chronic tension-type headache 2 Episodic migraine (with or without aura) Chronic migraine (with or without aura) Episodic cluster headache Chronic cluster headache
1. Headache pain can be felt in the head, face or neck. 2. Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.

Ottawa SAH rule

The ottawa SAH rule has a 100% sensitivity (but low specificity) for SAH. A patient with headache does not require investigations if then do not have any of:

  • age ≥40 years.
  • neck pain or stiffness.
  • witnessed loss of consciousness.
  • onset during exertion.
  • thunderclap headache [instantly peaking pain].
  • limited neck flexion on examination.

Content By Dr Íomhar O' Sullivan date. Last review Dr ÍOS 9/11/18.