Headache and facial pain, including primary and secondary headache disorders
Headache questions test whether you can separate primary from secondary headache quickly, recognise the red flags that mandate imaging or lumbar puncture, and match preventive and acute treatments to the syndrome.
Primary headaches
Migraine: unilateral, pulsating, moderate-severe, aggravated by activity, with nausea or photophobia/phonophobia; aura is typically visual and resolves in under an hour. Acute treatment is an NSAID or triptan; prophylaxis (propranolol, topiramate, amitriptyline, candesartan, CGRP monoclonal antibodies) is offered at four or more headache days per month with disability. Tension-type headache is bilateral, pressing, mild-moderate, without vomiting. Cluster headache is strictly unilateral orbital/temporal, 15-180 minutes, with ipsilateral lacrimation, ptosis, rhinorrhoea and restlessness; acute treatment is high-flow oxygen (12-15 L/min for 15-20 minutes) or subcutaneous sumatriptan 6 mg; prophylaxis is verapamil with an ECG before dose escalation. Paroxysmal hemicrania responds absolutely to indomethacin.
Red flags (SNOOP4)
Systemic symptoms or illness (fever, weight loss, HIV); Neurological deficit or papilloedema; Onset sudden (thunderclap - exclude subarachnoid haemorrhage, reversible cerebral vasoconstriction syndrome, venous thrombosis, pituitary apoplexy); Older age over 50 with new headache (giant cell arteritis); Pattern change or previous headache history changing. Add positional headache, headache in pregnancy or puerperium, cancer, immunosuppression, and trauma.
Secondary headaches to know
Giant cell arteritis: over 50, scalp tenderness, jaw claudication, visual loss, ESR/CRP raised - give corticosteroids immediately and arrange temporal artery biopsy within two weeks. Idiopathic intracranial hypertension: young woman with obesity, papilloedema, pulsatile tinnitus, transient visual obscurations, opening pressure above 25 cm CSF; treat with weight loss, acetazolamide, topiramate. Medication overuse headache: regular use of acute drugs 10-15 days per month. Low CSF pressure headache is postural and better lying flat. Trigeminal neuralgia is a lancinating electric shock in V2/V3 with a trigger zone, treated with carbamazepine.
Worked example
A 64-year-old with two weeks of left temporal headache, scalp tenderness and jaw pain on chewing has ESR 78 and CRP 60. The diagnosis is giant cell arteritis. Start prednisolone 40-60 mg daily immediately - do not wait for biopsy - arrange temporal artery biopsy within 1-2 weeks, and add aspirin plus bone protection. Visual loss already present is often irreversible, so urgency is the mark of a good answer.
Traps
Triptans are contraindicated in ischaemic heart disease, uncontrolled hypertension and stroke. Sumatriptan overuse causes medication overuse headache. Migraine aura without headache is not a stroke, but sudden-onset aura in a patient over 50 warrants vascular imaging. Cluster headache is distinguished from trigeminal neuralgia by duration and autonomic features.