Headache

Some tips before referral:

CT head? Do you want a clinical opinion or a CT head scan? – if just the latter then NHS D&G provides open access CT head. Remember, incidental finding (10%) vs. relevant finding (<0.5%), radiation dose is over 100 chest x-rays and studies suggest it doesn’t provide long-lasting reassurance
Acute treatments for migraine – have you tried soluble Aspirin 900mg, Sumatriptan 100mg, Almotriptan 12.5mg, rizatriptan 10mg with anti-emetics? If severe vomiting, try subcutaneous Sumatriptan 6mg.
Preventative treatment for migraine (see below links for more detail) – have you tried a Beta-blocker (eg Propanolol), Antiepileptic (Topiramate) or Tricyclic (eg Amitriptyline) at therapeutic doses for 3-4 months each.
Treatment of medication overuse headache – Stop regular analgesia (especially codeine) and limit acute treatment to 10x/month. Tell the patient they will feel worse for a while and wait for 3-4 weeks before expecting any benefit
Tackle insomnia and fatigue – Many patients with chronic daily headache also have insomnia and fatigue. Improving other causes of these symptoms can improve headache.+

Guide to differentiating headache

-	Migraine	Tension type	Cluster	Other trigeminal autonomic cephalgias*	Cervicogenic	Medication overuse
Frequency	1-several/month	Variable	Every other day to 1–8 per day	Multiple daily	Daily for weeks	15 or more days in a month
Severity	Moderate–severe	Mild–moderate	Severe–very severe	Moderate–severe	Moderate–severe	Mild–severe
Location	Unilateral or bilateral	Bilateral	Unilateral	Unilateral in trigeminal distribution centered around the eye	Posterior–unilateral	Bilateral (may mimic primary headache medication is used for)
Nature of pain	Throbbing/pulsating	Pressing/tightening	Severe unilateral pain	Severe – may be sometimes very brief	Ache radiating from neck/occipital region	Diffuse ache/pressure
Visual aura	+/- (present in a third of patients)	-	+/-	-	-	+/-
Duration	4–72 hours	Variable	15–180 minutes	Seconds – 30 min	Hours/constant	Hours/constant
Nausea	++	+/-	+/-	-	+/-	-
Photophobia	++	+/-	+ often ipsilateral	+/-	-	-
Vomiting	+	-	+/-	-	-	-
Activity	Keep still	Normal	Restless/pacing	Keep still or pace	Worse with neck movements/sleep & lifting	Normal
Examination	Normal	Tender points	Cranial autonomic features during attack	Cranial autonomic features during attack	Pain on neck movement and pressure	Normal
Suggested treatment	See following pages	See following pages	Refer all with new cluster	*Refer to neurology (routine)	See following pages	See following pages

Last reviewed: 19/05/2025

Next review date: 01/05/2027

Author(s): Ondrej Dolezal.