Headache and Facial Pain
Headache diagnosis is clinical. The exam tests the ICHD-3 criteria, the red flags that mandate imaging, and the fact that treatment choice follows the syndrome rather than the pain severity.
Migraine
At least five attacks lasting 4 to 72 hours, with at least two of unilateral location, pulsating quality, moderate to severe intensity and aggravation by activity, plus at least one of nausea or vomiting, or photophobia and phonophobia. Acute treatment is an NSAID or a triptan; prophylaxis includes propranolol, topiramate, amitriptyline, candesartan and CGRP monoclonal antibodies. Aura symptoms are fully reversible, spread over at least 5 minutes, and each lasts under 60 minutes.
Cluster headache
Attacks of 15 to 180 minutes, severe unilateral periorbital pain with ipsilateral lacrimation, rhinorrhoea, ptosis and restlessness, occurring up to eight times daily with circadian periodicity. Treat with high-flow oxygen at 12 to 15 litres per minute and subcutaneous sumatriptan 6 mg; verapamil is the prophylactic of choice with ECG monitoring.
Trigeminal neuralgia
Brief electric-shock paroxysms in the second or third division, triggered by touch, chewing or cold. Carbamazepine is first line; MRI is required to exclude a multiple sclerosis plaque or cerebellopontine angle mass. Microvascular decompression is the definitive surgical option.
Red flags (SNOOP)
Systemic symptoms, neurological signs, sudden thunderclap onset, age over 50 with new headache, and change in pattern.
Worked example
A 55-year-old reports two weeks of new bitemporal headache with jaw claudication and an ESR of 80. This is giant cell arteritis. Start high-dose corticosteroids immediately and arrange temporal artery biopsy within two weeks; treatment must not wait for the biopsy.
Traps
Labelling every frontal headache as sinusitis; missing medication overuse headache when analgesics are used on 15 or more days monthly; calling a thunderclap headache a migraine.