Headache - Approach




  • Have underlying cause
  • Meds. 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
  • ↓ level of consciousness
  • Recent (3 months) head trauma
  • Headache triggered by cough, valsalva
  • Headache triggered by exercise
  • Orthostatic (Δ with posture)
  • Symptoms of giant cell arteritis
  • Symptoms/signs of acute narrow-angle glaucoma
  • Substantial Δ in the characteristics of headache

Consider referral

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


  • Subarachnoid
  • Meningitis
  • ↑ICP (E.g SOL - 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 - retro-orbital pain with eye movement

Feature Tension headache Migraine (±aura) Cluster headache
Pain location Bilateral Unilateral or bilateral Unilateral (around/above the eye and side of the head/face)
Pain quality Pressing / tightening (non-pulsating) Pulsating (throbbing or 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 Aggravated by, or causes avoidance of, activities of daily living Restlessness/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 ±paraesthesia, ±speech disturbance.
Same side as headache:
- red and/or watery eye
- nasal congestion ±catarrah
- swollen eyelid
- forehead / facial sweating
- constricted pupil ±drooping eyelid.
Duration 30 minutes–continuous 4–72 hours in adults, 1–72 hours in young people aged 12–17 years 15–180 minutes
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 (more on SAH). A patient with headache does not require investigations for SAH if then do not have any of:

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

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 15/06/21.