The content in this section is intended for medical professionals, and adjusted to to our local practice in Dorset. More information can be found on the BASH website. You can also have a look at the presentations.
When to refer
Some headaches will need immediate investigations: If the headache came on suddenly, if the patient is systemically unwell, or if there is focal neurology or papilledema the patient should be sent to the A&E or SDEC where they will normally have imaging and sometimes lumbar puncture. If the patient is over 50 with a new headache, giant cell arteritis needs to be ruled out – rheumatology has an urgent helpline for this.
An urgent neurology referral or imaging should be considered if there is recent trauma, a recent history of cancer, if the patient is immunosuppressed or on anticoagulation. If the patient has pressure symptoms such as headache on coughing/sneezing/straining, sometimes with pulsatile tinnitus or diplopia, they will need both imaging and an urgent eye check. Severe headaches during (rather than after) sex or exercise will usually need imaging. , or if they have a severe headache during sex or exercise. Wake up headaches are very common and is not a red flag in itself.
If none of these apply it’s most likely a primary headache. Migraine is by far the most common cause of recurrent disabling headaches, and also a very a common cause for headaches presenting urgently to healthcare. Tension type headaches are more common in the population, but most patients never see a doctor for this. When someone with tension type headache do see a doctor, it’s often because they’re worried about a sinister cause.
Neurology doesn’t have capacity to see more than a small minority of patients with migraine. We focus on patients with chronic migraine and will usually not accept referrals unless the patient first have tried the standard treatments described on this website. We’re always happy to discuss cases on Advice & Guidance, and to see patients where the diagnosis is not clear, or where you suspect an unusual headache type such as cluster headaches. Hopefully the treatment advice below and in the links will be helpful.
Common Headaches
Most episodic headaches are either tension type headaches or migraine. The most important difference between the two is that migraine is more severe.
Tension type headaches are usually bilateral, feel like a pressure, wax and wane and can be brought on by common triggers such as dehydration, lack of sleep, stress, screen work. There can, but doesn’t have to be any muscle tension despite the name. It’s usually possible to continue activities, if needed with ordinary pain killers. There can be nausea or light sensitivity but this is mild.
Migraines vary in intensity but can often be disabling, so that the patient needs to stop activities and rest in a dark room. They come in attacks lasting 4-72 hours, often preceded by a prodrome of feeling irritable or fatigued, sometimes an aura with visual disturbance, pins and needles, or other neurological symptoms lasting up to an hour. An attack can be caused by the same triggers as tension type headaches, but also by alcohol, strong smells, too much sleep, or the menstrual period. The headache can be either unilateral or bilateral, often throbbing and focused around the eyes and temples, usually associated with light sensitivity, often with nausea.
Although tension type headaches are common, most can manage them with over the counter pain killers. If a patient sees their doctor to get help with recurrent disabling headaches, it’s likely to be migraine, also when it’s bilateral and without aura. If in doubt, arrange a trial of triptans and the other migraine treatments described here.
Chronic Headaches
There are chronic forms of tension type headache and migraine, but also some other causes.
Medication overuse headache is by definition present when someone has chronic headache and takes pain killers more than three days a week. It can also develop when someone takes opioids or combination tablets (Solpadeine, Migraleave etc) more than one day a week or triptans more than two days a week. Usually there is underlying migraine, that have gradually become worse in parallel with the patient taking more and more pain killers. Everyone with chronic headaches should therefore try to to stop all pain killers for at least two weeks and then see how the headache changes – this will improve the situation for around 50% of patients. Also see my blog.
Chronic migraine is defined as headache >15 days a month, of which 8 days have migraine characteristics. It affects 2% of the population but there are now many available treatments, both oral and injectable preventatives.
Neck-related headache, also called cervicogenic headache, is also common, especially at older age. Usually the headache is at the back of the head, with associated neck pain, and the headache gets worse by neck movements or sitting still for too long. It can also be brought on by lying down and is a common cause of morning headaches. A variant is occipital neuralgia, where a trapped nerve in the neck (C3, or greater occipital nerve) causes a burning pain on one side of the back of the head. Treatment is physiotherapy. Amitriptyline, gabapentin, pregabalin can be considered. Imaging is not needed. Other musculoskeletal pain, e.g. TMJ pain or shoulder pain, can also trigger a secondary headache which is treated like tension type headache.
Chronic daily persistent headache is similar to chronic tension type headache but describes when the headache came one day and never went away. This can also happen with COVID-19 infection. Amitriptyline can be tried.
Rare Headaches
Each of these are more than a hundred times rarer than migraine, and often over diagnosed. Always consider if the pain could be a migraine variant instead.
Cluster headaches come in attacks lasting 30-240 minutes, often between 2-8 every 24 hours, more at night. The pain can be excruciating, usually centred around one eye which can become swollen, droopy, bloodshot and watery. Often this goes on for 3-6 weeks at a time, with many pain free months in between, but there is also a chronic variant. Prescribe sumatriptan or zolmitriptan nasal spray, or sumatriptan injection – this can be used up to four times a day. You can also start Verapamil 120mg MR bd, which sometimes need to be increased up to 480mg bd. Check ECG before and after verapamil dose changes to make sure the PR interval is normal, and infrequently during treatment. Refer to neurology and we will consider MRI Brain and discuss other treatment options such as oxygen, topiramate, steroids, lithium, and the GammaCore. You can read more on the BASH website.
Trigeminal neuralgia consists of sharp brief attacks of pain in one trigeminal dermatome, usually along the lower jaw. It can be triggered by chewing but also by touch or a draft. Treatment is carbamazepine in increasing doses, often up to 1600mg daily, check FBC, U&E, LFT after treatment start. An alternative is gabapentin. If acute onset consider a course of acyclovir to cover shingles. Refer if refractory, if they’re under 50, or if examination is abnormal – it’s common to be hypersensitive in the area, but if they’re instead numb, or has reduced corneal reflex, they need imaging. It can easily be confused with dental pain or TMJ pain, so the patient should also see their dentist.
Idiopathic Intracranial Hypertension can sometimes cause a migraine-type headache, but more typically a pressure type headache brought on by coughing or lying down, associated with pulsatile tinnitus, and visual disturbances. Mainly affects young obese women as part of a metabolic syndrome. To rule out IIH is one of the reasons that everyone with frequent headaches should have an eye exam. If papilledema is found, send immediately to the Eye Unit or SDEC for diagnosis. If no papilledema there is usually no need to consider this diagnosis.
Paroxysmal hemicrania is similar to cluster headache but even rarer, with attacks of unilateral pain involving the eye, lasting 5-30 minutes up to 50 times daily. Treatment is indomethacin, and response confirms diagnosis. Prescribe indomethacin 25mg tds with omeprazole, increase to 50mg tds after a week if not effective. Refer to neurology to confirm diagnosis.
Ice-pick headache or primary stabbing headache consists of attacks lasting seconds, often moving between different parts of the scalp. This is often associated with migraine and can respond to migraine preventatives. Indomethacin or NSAID is effective but usually not practical. Reassurance is often sufficient, will not need referral or imaging.
Hypnic headache is an unspecific morning headache that mainly affects elderly women. A strong cup of coffee at bedtime can resolve it, as can melatonin. Amitriptyline can also be tried. If in doubt, refer.
Nummular headache is a chronic or episodic headache in a small, often coin-sized, area of the scalp. Gabapentin or amitriptyline can be tried, and more recently also botox injections in the painful area. Occasionally part of systemic / autoimmune disease, so check general blood tests. Refer if persistent.
Secondary headaches
Headache can be a sign of underlying illness. Contrary to common belief, this is very rarely a brain tumour. The following list is by no means complete, so always ask your patient for general symptoms and arrange investigations accordingly.
Anaemia, diabetes, thyroid disease could all have an unspecific headache as part of the symptoms. We recommend blood tests when someone presents with a new headache. Also check blood pressure, but hypertension is usually not the sole cause of headaches.
Obstructive sleep apnoea often causes wake up headaches.
Connective tissue disease such as SLE, Sjogren, Behcet, anti-phospholipid syndrome have an increased risk of headaches, sometimes as an early symptoms; both migraine-type headaches but occasionally also serous meningitis. If a patient with known connective tissue disease develops worsening headache, there should be a lower threshold of imaging, and changing the DMT might help. Otherwise treat like migraine.
Medication side effects. Many medications can cause headaches, so if they started after a medication change consider reversing this temporarily at least. Nitroglycerin for ischaemic heart disease causes vasodilation and therefore has headache as a very common side effect, this can also occur with sildenafil and tadalafil for erectile dysfunction. Contraceptives often causes headaches. This can also occur with the mirena coil and HRT, but starting these can also often make migraines milder. The same is true for SSRI that can make migraines either better or worse.
Anxiety and low mood is a very co-morbidity especially in chronic headaches. Many of the migraine preventatives can work for both. Addiction of any kind can also cause headaches – both due to the substance itself and also as it is associated with stress, anxiety, irregular sleep and diet. This includes nicotine, caffeine, and internet/gaming.