Clinical Guides
Approach to Headache
A clinically focused, safety-first approach to headache in adults and adolescents, from phenotype and medication overuse to time-critical secondary causes, rational imaging, pregnancy and access-aware care in India.
MedNext Academy | 14 min read
Approach to Headache
A clinically focused, safety-first approach to headache in adults and adolescents, from phenotype and medication overuse to time-critical secondary causes, rational imaging, pregnancy and access-aware care in India.
Summary
Headache assessment is a triage problem before it is a naming exercise. The first decision is whether this is a familiar primary headache, a secondary headache requiring investigation, or an emergency in which investigation and treatment must proceed together. Sudden pain reaching maximum intensity within minutes, fever with meningism, new focal deficit, impaired consciousness, papilloedema, a painful red eye, pregnancy or puerperium, cancer, immunosuppression and a new headache after age fifty all alter urgency. A normal early examination cannot by itself exclude subarachnoid haemorrhage, cerebral venous thrombosis, meningitis or an evolving intracranial pressure disorder.
Once immediate danger is addressed, describe the phenotype rather than using pain intensity alone. Onset, time to peak, duration, frequency, location, quality, aggravation by activity or posture, autonomic features, aura, nausea, photophobia and functional loss separate migraine, tension-type headache and trigeminal autonomic cephalalgias. Record acute medicines and days of use because medication-overuse headache can perpetuate an otherwise treatable disorder.
Most stable primary headaches are diagnosed clinically. Neuroimaging is not a screening test for every headache and should not be ordered solely for reassurance. Select CT, MRI, vascular imaging, venography, lumbar puncture or ophthalmic assessment according to the suspected pathology and timing. Treatment joins an acute plan, prevention when burden warrants it, trigger and sleep advice, reproductive safety, and follow-up that checks both benefit and harm. This draft is educational, has been reviewed by the MedNext Clinical Team and does not replace local emergency protocols or individual prescribing.
How Common Is It?
Headache is among the most frequent neurological symptoms, but population estimates vary with age range, recall period, diagnostic criteria and whether a study measures any headache or a specific disorder. Migraine and tension-type headache account for much of the community burden. Their frequency should never be used to dismiss a first, abrupt or changing presentation. Conversely, fear of a brain tumour should not drive routine scanning when history and examination fit a stable primary headache without red flags. The value of prevalence is to set a sensible prior probability, not to overrule the patient in front of the clinician.
Burden is better expressed through headache days, disability days, school or work loss, emergency attendance and medication exposure than through a yes-or-no diagnosis. Episodic disorders can become chronic, and frequent rescue treatment can become part of the problem. Ask how many days in a typical month involve headache, how many involve migraine features, and how many involve an analgesic, triptan, ergot, opioid or combination product. A diary kept for several weeks reveals patterns that memory often obscures.
Indian practice spans home treatment, pharmacies, primary health centres, private clinics and tertiary neuroscience services. Easy non-prescription access may delay assessment or foster repeated combination-analgesic use. At the other extreme, unnecessary CT exposes people to cost and radiation without resolving a primary headache. A high-quality pathway therefore combines reliable red-flag screening, a positive clinical diagnosis when justified, explicit return precautions and proportionate referral.
Risk Factors
Risk factors should be linked to particular diagnoses rather than treated as a generic list. Migraine susceptibility is influenced by family history, biological sex, hormonal transitions and sleep disruption. Attacks may be associated with missed meals, dehydration, stress, menstruation or irregular routines, but a temporal association does not prove causation. Encourage patients to identify reproducible personal patterns rather than adopt restrictive diets based on long lists of alleged triggers. Obesity and recent weight gain increase concern for idiopathic intracranial hypertension when headache accompanies transient visual obscurations, pulsatile tinnitus or papilloedema.
Secondary headache risk changes with context. Pregnancy and the first six postpartum weeks raise concern for hypertensive disorders, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome and pituitary disease. Oestrogen exposure, thrombophilia, dehydration and infection also modify venous thrombosis risk. Cancer, HIV, immunosuppressive treatment and systemic infection increase the probability of intracranial infection or mass lesions. Recent trauma raises concern for haemorrhage, particularly with anticoagulants, older age or alcohol dependence. Age over fifty with a new headache, scalp tenderness, jaw claudication or visual symptoms requires prompt consideration of giant cell arteritis.
Medicine history is diagnostic. Frequent acute treatment can produce medication-overuse headache; current guidelines thresholds include use for three months or more of triptans, opioids, ergots or combination analgesics on at least ten days per month, or paracetamol, aspirin or an NSAID on at least fifteen days per month. Other exposures may signal danger: anticoagulants, retinoids, tetracyclines, sympathomimetics and abrupt caffeine withdrawal can change the differential. Risk raises or lowers suspicion but never substitutes for chronology and examination.
Diagnosis
History
Start with the exact first moment and ask how long pain took to peak. Clarify whether this is the first, worst, abruptest or substantially changed headache. Document duration, monthly frequency, pain-free periods, laterality, site, quality, severity and effect of routine activity. Ask about fever, rash, neck stiffness, vomiting, seizure, syncope, focal symptoms, confusion, trauma, cough or exertional onset, posture, pregnancy, postpartum timing, cancer, immune compromise and medicines. Characterise visual, sensory or language symptoms by evolution and reversibility; a typical aura develops gradually, whereas a sudden persistent deficit is a stroke until assessed. Record every acute remedy and its days of use.
Examination
Measure temperature, pulse, blood pressure and oxygen saturation, and assess consciousness before a detailed examination. Severe hypertension with neurological, cardiac, renal or obstetric features may represent an emergency, but headache alone does not prove pressure-mediated injury. Perform cranial nerve, motor, sensory, coordination, reflex and gait examination. Look for meningism, rash, temporal-artery tenderness, jaw or tongue ischaemic symptoms, sinus or dental clues and signs of trauma. Examine visual acuity, pupils, fields, ocular movements and the red eye; fundoscopy should actively seek papilloedema but an apparently normal view by an inexperienced examiner is not definitive.
Investigations
Investigations answer a defined question. Emergency non-contrast head CT is commonly first-line for suspected acute haemorrhage; a negative result does not end the pathway when clinical suspicion remains, because sensitivity varies with time, scanner and interpretation. Follow the local subarachnoid haemorrhage pathway for CT timing, lumbar puncture and angiographic imaging. MRI is often more informative for posterior fossa, pituitary, inflammatory, pressure-related or subacute lesions, while CT or MR venography addresses venous thrombosis. Suspected meningitis needs a time-critical emergency pathway; cultures, imaging and lumbar puncture depend on stability and contraindications. Pregnancy testing, ESR/CRP and platelet count, ocular pressure assessment or targeted blood tests are used only when the differential supports them.
Differential Diagnosis
Primary headache is diagnosed from a positive pattern after safety screening. Migraine commonly lasts hours, impairs activity and includes nausea or sensitivity to light and sound; aura is fully reversible and usually evolves over minutes. Tension-type headache is generally pressing or tightening, mild to moderate, bilateral and not worsened by routine activity. Cluster headache produces excruciating strictly unilateral orbital or temporal pain with ipsilateral lacrimation, nasal symptoms, ptosis or restlessness in repeated shorter attacks. Other trigeminal autonomic cephalalgias and neuralgias need specialist discrimination because attack duration and treatment differ.
Secondary causes are organised by tempo. A thunderclap demands assessment for subarachnoid haemorrhage, reversible cerebral vasoconstriction, venous thrombosis, cervical artery dissection, pituitary apoplexy and other vascular events. Fever, rash, neck stiffness or altered cognition suggests meningitis or encephalitis. Progressive morning or Valsalva-related pain, vomiting, papilloedema, focal deficit or seizure raises concern for mass effect or raised intracranial pressure. New headache with visual symptoms or jaw claudication after fifty suggests giant cell arteritis; a painful red eye with haloes, reduced vision, a mid-dilated pupil or nausea suggests acute angle-closure glaucoma.
Pregnancy and puerperium warrant a deliberately broad differential: pre-eclampsia or eclampsia, venous thrombosis, reversible vasoconstriction, posterior reversible encephalopathy, dissection, haemorrhage and pituitary disease coexist with migraine. Orthostatic headache suggests low cerebrospinal-fluid pressure, while headache worse supine with transient visual obscurations may suggest raised pressure. Medication overuse, carbon monoxide exposure, sleep apnoea, acute sinus or dental disease and systemic metabolic illness are considered from context. Do not call a headache sinusitis solely because facial pressure accompanies nasal symptoms, and do not call it hypertensive solely because one distressed reading is high.
Management
Immediate management follows the threatened organ, not the eventual headache label. Stabilise airway, breathing and circulation; check glucose and treat seizures. Activate stroke, subarachnoid haemorrhage, meningitis, acute glaucoma or obstetric emergency pathways when indicated. If bacterial meningitis is suspected, obtain appropriate cultures but do not allow imaging or lumbar puncture to create an unsafe delay in emergency care. Suspected giant cell arteritis with threatened vision requires a same-day specialist pathway and diagnostic plan. Papilloedema, reduced consciousness or focal deficit requires urgent neuroimaging before lumbar puncture.
For a stable primary headache, explain the diagnosis and give a written acute plan. Migraine care may use an appropriate triptan with an NSAID or paracetamol, or a single agent when combination treatment is unsuitable, with an antiemetic if needed. Avoid opioids and routine ergots. Tension-type headache may respond to a simple analgesic used within safe limits. Cluster headache needs rapid specialist-supported treatment; high-flow 100% oxygen through a non-rebreathing mask and a suitable subcutaneous or nasal triptan are evidence-based options, while oral analgesics are too slow.
Discuss prevention when attacks are frequent, disabling, prolonged, poorly responsive or driving hazardous acute-medication use. Choose a preventive through shared decision-making, accounting for comorbidity, pregnancy potential, monitoring, cost and availability; set a time-limited trial and measure headache days and disability. A diary, regular sleep and meals, hydration, activity, caffeine moderation and management of anxiety or sleep apnoea can complement medication. Medication-overuse management requires a planned withdrawal conversation, realistic warning that headache may briefly worsen, rescue boundaries and follow-up. Do not replace repeated analgesics with another frequently used rescue product.
Prescribing Information
Before prescribing, establish pregnancy status, relevant comorbidity, concurrent medicines, product-specific contraindications and the number of acute-treatment days per month. Ask specifically about non-prescription and combination products, because an ingredient can be duplicated across products. Current guidelines recommends an oral triptan with either an NSAID or paracetamol for acute migraine when suitable; a single triptan, NSAID, aspirin or paracetamol is an alternative when combination treatment is unsuitable. It advises against opioids and ergots for acute migraine, and against opioids for acute tension-type headache. These are treatment choices, not a substitute for the individual product information or a medication-reconciliation review.
For migraine prevention, discuss the benefits, risks and suitability of propranolol, topiramate or amitriptyline in the context of comorbidity and adverse-effect risk. Topiramate must not be used for migraine prophylaxis in pregnancy; for people who can become pregnant, its use requires the applicable pregnancy-prevention safeguards. For a cluster bout, verapamil should be considered only with specialist advice when the prescriber is unfamiliar with its use, including advice on ECG monitoring. Do not extrapolate one medicine's contraindications or maximum daily dose to another; follow the current Indian product information and specialist pathway.
During pregnancy, current guidelines identifies paracetamol as the acute migraine option and requires an individual risk discussion before considering a triptan or NSAID; preventive treatment needs specialist advice. New or atypical headache still requires a secondary-cause assessment. Agree a measurable outcome, review treatment-day exposure and adverse effects, and reassess the diagnosis when the pattern changes. This educational draft intentionally provides no dose schedule; exact strengths, routes, maximum doses and monitoring must come from current Indian product information, formulary and specialist guidance.
When to Refer
Transfer immediately to an emergency-capable service for thunderclap headache; headache with reduced consciousness, seizure, new focal neurological deficit or rapidly progressive symptoms; fever with meningism or a non-blanching rash; papilloedema; acute painful red eye with visual loss; or severe headache in pregnancy or puerperium with hypertension, neurological features or systemic illness. Suspected subarachnoid haemorrhage needs time-critical investigation even if pain has improved. Suspected meningitis needs treatment during transfer planning. Visual symptoms with suspected giant cell arteritis require same-day specialist pathways because delay can cost sight.
Urgent referral is also appropriate for a new headache with cancer or significant immune compromise, a new pattern after age fifty, headache precipitated by cough or exertion, persistent vomiting without explanation, suspected raised intracranial pressure, venous thrombosis, pituitary apoplexy or dissection. A first cluster-headache bout merits specialist confirmation and consideration of imaging. New motor weakness, prolonged atypical aura or uncertain transient neurological symptoms should enter a stroke-aware pathway rather than being labelled complex migraine remotely.
Routine neurology or headache referral is reasonable when diagnosis remains uncertain, disabling migraine has not responded to well-conducted acute and preventive trials, chronic headache persists despite medication-overuse management, or advanced therapies are being considered. Refer earlier when comorbidity, pregnancy planning or medicine risk makes prevention complex. Ophthalmology, obstetrics, infectious diseases, rheumatology, dentistry or mental-health services may be the correct destination. A referral must state the phenotype, frequency, examination, red flags, treatments tried, treatment-day count and precise question. Continue primary-care safety-netting while waiting; referral is not a substitute for ownership.
Red Flags
A red flag changes action only when interpreted and acted upon. The highest-priority pattern is thunderclap headache: pain maximal at onset or within minutes, especially with collapse, vomiting, meningism, exertion or neurological symptoms. Treat it as possible subarachnoid haemorrhage until an appropriate pathway has excluded it. Fever, rash, neck stiffness, photophobia, altered behaviour or declining consciousness raises meningitis or encephalitis concern. New focal deficit, seizure, diplopia, ataxia or persistent confusion requires urgent neurological assessment even when migraine is in the history.
Raised intracranial pressure is suggested by papilloedema, progressive headache, repeated vomiting, transient visual obscurations, sixth-nerve palsy or pain aggravated by Valsalva or recumbency. Do not perform lumbar puncture before appropriate assessment when mass effect or obstructed cerebrospinal-fluid flow is possible. In a person over fifty, a new headache with scalp tenderness, jaw or tongue claudication, constitutional features, polymyalgia symptoms or visual disturbance demands urgent giant-cell-arteritis action. Sudden painful red eye, cloudy cornea, haloes, reduced acuity, nausea or a fixed mid-dilated pupil suggests acute angle closure.
Pregnancy and the postpartum period lower the threshold for urgent assessment, particularly with hypertension, proteinuria symptoms, seizure, focal deficit, breathlessness or a new severe pattern. Other warnings include recent significant trauma, anticoagulation, cancer, immunosuppression, positional or exertional onset, substantial pattern change, and persistent unexplained vomiting. Medication overuse is a harm signal rather than a licence to ignore new red flags. Give explicit return instructions: worsening pain, fever, fainting, weakness, speech or visual change, repeated vomiting, seizure or inability to obtain follow-up should trigger urgent re-evaluation.
Indian Clinical Context
The core safety sequence works at every level: recognise danger, stabilise, select the correct destination and document the handover. A health and wellness centre may not have CT, lumbar puncture or tonometry, but it can identify thunderclap onset, meningism, focal deficit, papilloedema suspicion, a red painful eye or an obstetric emergency and arrange time-critical transfer. Do not allow an unavailable test to become a reason for reassurance. Conversely, in a stable recurrent migraine with a normal examination and no change in phenotype, an expensive scan may consume resources without improving outcome.
Differentials reflect local epidemiology without stereotypes. Tuberculosis, neurocysticercosis, HIV-related infection and cerebral venous thrombosis may be relevant when exposure, immune status, seizure, focal findings, papilloedema or imaging supports them; headache alone does not justify empiric antitubercular or antiparasitic treatment. Postpartum dehydration, anaemia, sepsis and delayed access can compound venous-thrombotic risk. Ask privately about pregnancy possibility and contraception before imaging contrast or teratogenic prevention, and avoid moral assumptions about marital status.
Non-prescription combination analgesics are widely accessible and may contain caffeine or duplicate paracetamol. Ask the patient to bring strips, photographs or receipts and count medicine days, not just tablets. Explain withdrawal and prevention in the patient's language; a diary may use paper symbols when literacy or smartphone access is limited. When MRI, venography, ophthalmology or neurology is distant, choose the safest available bridge and name who will track the referral. The NMC competency framework supports integrated reasoning across Medicine, Ophthalmology, Obstetrics, Pharmacology and Emergency care, while the final plan must follow local protocols and current Indian formularies.
NMC Competency Mapping
This approach integrates NMC outcomes rather than attaching a headache to one isolated code. In Medicine, learners should elicit and document a focused neurological history, perform a complete neurological and general examination, construct a reasoned differential, select investigations and recognise emergencies including meningitis, stroke, raised intracranial pressure and subarachnoid haemorrhage. Pharmacology outcomes apply to rational analgesic use, adverse effects, contraindications, interactions, antimicrobial urgency and preventive medicines. Ophthalmology contributes visual acuity, pupil examination, fundoscopy, papilloedema and acute glaucoma recognition. Obstetrics contributes hypertensive disorders, venous thrombosis and neurological emergencies in pregnancy and puerperium.
A competent learner should be able to present onset-to-peak time, phenotype, red flags and medicine-day exposure in a concise problem representation. They should distinguish a positive migraine or tension-type pattern from a diagnosis of exclusion, and explain why imaging is needed for one patient but not another. They must know that a negative test is interpreted in context: early CT performance for subarachnoid haemorrhage depends on timing and expertise, and a normal fundus view does not negate other danger features.
Workplace assessment can use observed history, cranial-nerve and fundus examination, an imaging request with a stated clinical question, a safe referral handover and counselling about acute-medication limits. Case discussion should test pregnancy safety, giant cell arteritis, meningitis, acute angle closure, medication overuse and the hazards of indiscriminate imaging. The expected graduate behaviour is not memorising a mnemonic alone; it is recognising uncertainty, escalating proportionately and giving the patient a feasible follow-up and return plan.
Key Exam Pearls for NEET PG
Thunderclap is a description of timing, not a diagnosis. Subarachnoid haemorrhage is the classic cause, but venous thrombosis, reversible cerebral vasoconstriction, dissection and pituitary apoplexy remain important. In suspected subarachnoid haemorrhage, investigation follows a time-sensitive local pathway; neither transient improvement nor an isolated normal neurological examination excludes it. Papilloedema implies raised intracranial pressure until assessed, whereas pulsatile tinnitus and transient visual obscurations in a young person with weight gain suggest idiopathic intracranial hypertension. Lumbar puncture is unsafe before appropriate imaging when mass effect is suspected.
Migraine aura is usually fully reversible, develops over minutes and lasts under an hour; abrupt persistent negative symptoms demand stroke assessment. Cluster headache combines short, severe unilateral orbital or temporal attacks with ipsilateral autonomic signs or restlessness; acute therapy uses high-flow oxygen and a fast non-oral triptan, while verapamil prevention requires ECG monitoring. Medication-overuse thresholds differ: ten days monthly for triptans, opioids, ergots or combination analgesics, and fifteen for simple analgesics, sustained for three months in the relevant clinical context.
New headache after fifty with jaw claudication or visual symptoms suggests giant cell arteritis; headache with a red painful eye, haloes and reduced vision suggests acute angle-closure glaucoma. Pregnancy or puerperium plus severe headache, hypertension, seizure or focal deficit is an obstetric-neurological emergency. Stable primary headache without red flags does not require routine neuroimaging for reassurance. Imaging sensitivity depends on timing, technique and expertise; treatment evidence reports average benefit rather than guaranteed cure. Exam answers should specify the next safest action and diagnostic question, not simply choose MRI because it is more detailed.
Frequently Asked Questions
Does every severe or recurrent headache require a brain scan?
No. Severity alone does not determine imaging. A stable recurrent headache that meets a primary-headache pattern, has a normal appropriate examination and has no red flags is usually diagnosed clinically. Imaging is selected when onset, progression, examination or context suggests a secondary cause, and the modality should answer that question. Scanning solely for reassurance can reveal incidental findings without improving care.
What makes a thunderclap headache an emergency even if the pain improves?
Thunderclap describes pain that reaches maximum intensity immediately or within minutes. Subarachnoid haemorrhage, reversible cerebral vasoconstriction, venous thrombosis and dissection may present this way, and neurological examination may initially be normal. Improvement after analgesia does not exclude them. The patient needs urgent, time-sensitive investigation under a local emergency pathway rather than routine outpatient imaging.
How should medication-overuse headache be recognised and discussed?
Ask about treatment days per month for every prescription, pharmacy and combination product. Over at least three months, concern arises around ten days monthly for triptans, opioids, ergots or combination analgesics and fifteen days for paracetamol, aspirin or NSAIDs. Explain that the medicine may now maintain headache, plan withdrawal and prevention together, warn about temporary worsening and arrange follow-up without blame.
Which headache features need special urgency during pregnancy or after delivery?
A new severe or rapidly changing headache in pregnancy or the first postpartum weeks needs a lower threshold for urgent assessment, especially with high blood pressure, visual symptoms, epigastric pain, seizure, focal deficit, fever or breathlessness. Pre-eclampsia or eclampsia, cerebral venous thrombosis, haemorrhage, reversible vasoconstriction and pituitary disease must be considered alongside migraine. Medication choices also require pregnancy-specific review.
Inside MedNext for this topic
- 411 MedNext-authored chapters
- 80,000+ MCQ bank
- 15 study modes
- a growing library of visual revision sheets
Study modes
- Notes
- MCQ
- Audio
- Video
- Visual
- 3D Anatomy
- Trace
- Flashcards
- Mnemonics
- Image Bank
- Clinical
- Microscopy
- Audio QBank
- Cadaver
- Book Match
Continue reading
Clinical GuidesAll Clinical Guides
Browse all clinical management guides for Indian medical practice.
Test your knowledge
Attempt structured MCQs on this topic to consolidate your understanding and connect the guide to exam-focused practice.
Try MCQs on this topic