Headache and facial pain
Headache and facial pain
The exam tests primary headache diagnosis, secondary headache red flags, trigeminal neuralgia, and emergency treatment. Use SNOOP10 red flags: systemic symptoms, neurologic deficit, sudden onset, older age, pattern change, positional features, papilledema, pregnancy, painful eye, and trauma. Migraine is episodic, unilateral, pulsating, worsened by activity, with nausea or photophobia; treat acute attacks with NSAIDs or triptans and prevent with beta-blockers, topiramate, or amitriptyline. Cluster headache causes severe periorbital pain with autonomic signs and is treated acutely with high-flow oxygen or subcutaneous triptan. Trigeminal neuralgia responds to carbamazepine. Giant cell arteritis requires urgent steroids.
Worked example
A 55-year-old has sudden severe thunderclap headache. Reasoning: exclude subarachnoid hemorrhage with CT and, if needed, lumbar puncture; do not treat as migraine before imaging. A new headache with jaw claudication and elevated ESR suggests giant cell arteritis and needs corticosteroids immediately.
Traps
Do not miss medication-overuse headache; do not give triptans to patients with uncontrolled vascular disease; do not delay steroids in suspected giant cell arteritis; do not use opioids as first-line migraine therapy; remember that cluster headache is not treated with oral triptans as effectively as subcutaneous or oxygen.