Headache, pain and cranial nerve disorders
This domain tests ICHD-3 criteria, recognition of dangerous secondary headaches, and the pharmacology of acute and preventive headache treatment and neuropathic pain.
Migraine
At least five attacks of 4–72 hours with ≥2 of unilateral, pulsating, moderate-to-severe, aggravated by activity, plus ≥1 of nausea/vomiting or photophobia and phonophobia. Aura is fully reversible, spreads gradually over ≥5 minutes and lasts ≤60 minutes. Acute treatment: NSAIDs, triptans (contraindicated in coronary disease and uncontrolled hypertension), antiemetics. Prevention: beta-blockers, topiramate, amitriptyline, valproate, or CGRP monoclonal antibodies.
Medication-overuse headache
Headache on ≥15 days per month with regular overuse (triptans, ergots or opioids ≥10 days; simple analgesics ≥15 days) for more than 3 months.
Other primary headaches
Tension-type: bilateral, pressing, mild-to-moderate, no vomiting. Cluster headache: severe unilateral orbital pain for 15–180 minutes, ipsilateral autonomic signs (ptosis, lacrimation, rhinorrhoea) and restlessness; treat with 100% oxygen 12–15 L/min and subcutaneous sumatriptan; prevent with verapamil. Paroxysmal hemicrania responds to indomethacin.
Cranial nerve disorders
Trigeminal neuralgia: paroxysmal electric-shock pain in V2/V3 with trigger zones; carbamazepine is first-line; MRI excludes secondary causes. Bell palsy: peripheral facial weakness, eye protection, corticosteroids within 72 hours. Giant cell arteritis: age >50, new headache, jaw claudication, raised ESR/CRP - start steroids immediately and confirm by temporal artery biopsy or ultrasound.
Red flags (SNOOP4)
Systemic symptoms, neurological deficit, sudden onset, older age, pattern change, positional features, papilloedema, pregnancy or puerperium. Idiopathic intracranial hypertension: young woman with obesity, papilloedema, pulsatile tinnitus, treated with acetazolamide and weight loss.
Neuropathic pain
First-line: gabapentin, pregabalin, amitriptyline or duloxetine; postherpetic neuralgia and painful diabetic neuropathy are the commonest indications.
Worked example
A 45-year-old has attacks of severe right orbital pain lasting 60 minutes, occurring twice nightly for 3 weeks, with ptosis, tearing and restlessness. Stable, strictly unilateral attacks with ipsilateral autonomic features are cluster headache - start high-flow oxygen and subcutaneous sumatriptan, and verapamil for prevention.
Traps
Treating cluster headache with oral triptans; missing giant cell arteritis and delaying steroids; diagnosing sinus headache; failing to ask about analgesic overuse; missing papilloedema.