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Headache and migraine
The first step in every headache is looking for warning signs (sudden "worst ever" pain, fever and neck stiffness, a neurological deficit, age over 50 with new pain, a change in pattern); without them most headaches are primary — migraine, tension-type or cluster headache — and treatment follows the type.
Why it matters in the exam
The question presents a headache and asks whether imaging is needed or what the treatment is. A sudden headache peaking within a minute requires CT at once to exclude subarachnoid haemorrhage; if the CT is done beyond 6 hours from onset and is normal — lumbar puncture. Over age 50 with temple pain, jaw pain on chewing and visual disturbance, temporal arteritis is suspected: ESR and CRP, and steroids at once before the biopsy to prevent blindness. A young overweight woman with headache and papilloedema — idiopathic intracranial hypertension: imaging, a puncture with opening pressure and acetazolamide.
Migraine: one-sided throbbing pain, nausea, sensitivity to light and noise, lasting 4–72 hours. Attack treatment: NSAIDs or a triptan (not in ischaemic heart disease). Preventive treatment when there are 4 or more migraine days a month: propranolol, topiramate, amitriptyline or anti-CGRP antibodies. Migraine with aura is a contraindication to combined oestrogen pills (stroke risk). Cluster headache: a man, severe pain around the eye with tearing and rhinorrhoea on the same side, 15–180 minutes — 100% oxygen by mask and injected sumatriptan; prevention with verapamil. Overuse of painkillers (simple ones 15 days a month or more, triptans 10 days or more) causes daily headache — the drug is stopped.
Key points
- Look for warning signs before any diagnosis.
- Sudden pain: CT; beyond 6 hours and normal — lumbar puncture.
- Over 50: temporal arteritis — steroids at once.
- Migraine: NSAIDs or a triptan; prevention at 4 days a month or more.
- Cluster: 100% oxygen; overuse: stop painkillers.
Summary table
| Type | Clue | Treatment | Exam note |
|---|---|---|---|
| Subarachnoid haemorrhage | Sudden pain, peak within a minute | CT at once; beyond 6 hours and normal — lumbar puncture | "Worst ever" |
| Temporal arteritis | Over 50, temple pain, jaw pain, vision | ESR, CRP, steroids at once | Before the biopsy |
| Migraine | One-sided, throbbing, nausea, 4–72 hours | NSAIDs or a triptan; prevention at 4 days a month or more | Triptan not in heart disease |
| Cluster headache | A man, around the eye, same-side tearing and rhinorrhoea, 15–180 minutes | 100% oxygen, injected sumatriptan; verapamil | Attacks in seasons |
| Tension-type headache | Two-sided pressure, no nausea | Simple painkillers | The most common |
| Medication overuse | Painkillers 15 days a month, triptans 10 days | Stop the drug | Daily headache |
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Sources
- International Classification of Headache Disorders (ICHD-3), 2018 — Migraine, tension-type, cluster, medication-overuse headache
- American Headache Society Consensus Statement: Integrating New Migraine Treatments, 2021 — Acute and preventive treatment
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Headache; Migraine and Other Primary Headache Disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.