Headache and migraine

Quick Overview

Headache is one of the most common presentations in primary and secondary care. This chapter focuses on migraine (primary headache disorder affecting ~15% of UK population) and red flag features requiring urgent investigation to exclude secondary causes (subarachnoid haemorrhage, temporal arteritis, raised ICP). NICE CG150 provides evidence-based guidance on diagnosis, acute management, and prophylaxis strategies essential for safe practice.

Core Facts & Concepts

🚩 Red Flags (SNOOP4):

• Systemic symptoms (fever, weight loss, immunosuppression)
• Neurological signs/symptoms (focal deficit, seizure, altered consciousness)
• Onset sudden/thunderclap (<1 minute to peak = SAH until proven otherwise)
• Older age (new onset >50 years = consider temporal arteritis)
• Pattern change (frequency, severity, character)
• Positional (worse lying down = ↑ICP; worse standing = ↓CSF pressure)
• Precipitated by Valsalva (cough, sneeze = space-occupying lesion)
• Papilloedema or pregnancy

Migraine Diagnostic Criteria (≥5 attacks):

• Headache lasting 4-72 hours (untreated)
• ≥2 of: unilateral, pulsating, moderate-severe intensity, aggravated by routine activity
• ≥1 of: nausea/vomiting, photophobia + phonophobia
• Aura: reversible visual/sensory/speech symptoms developing over 5-60 minutes

Medication Overuse Headache (MOH):

• Headache ≥15 days/month in patient with pre-existing headache disorder
• Regular overuse for >3 months: triptans/opioids/combination analgesics ≥10 days/month OR simple analgesics ≥15 days/month

Problem-Solving Approach

Acute Migraine Management Ladder (NICE CG150):

1. First-line: Oral triptan (e.g., sumatriptan 50-100mg) + NSAID (ibuprofen 400-600mg) OR triptan + paracetamol 1g
2. If vomiting/rapid relief needed: Consider nasal/SC triptan or antiemetic (metoclopramide 10mg)
3. Contraindications to triptans: Uncontrolled HTN, IHD, previous stroke, hemiplegic migraine
4. Avoid: Opioids (risk of MOH) and ergots (inferior efficacy)

Prophylaxis Indications (offer if ≥2 attacks/month impacting QoL):

• Trial each for 3 months before switching
• Botulinum toxin A: Specialist option for chronic migraine (≥15 headache days/month)

Analysis Framework

Differentiating Primary vs Secondary Headaches:

⭐ Clinical Pearl: Cluster headache occurs in circadian patterns (same time daily, often waking from sleep). Male predominance 3:1.

Visual Aid

MOH Management Protocol:

• Abruptly stop overused medication (no evidence for gradual withdrawal)
• Warn: headache may worsen initially for 2-4 weeks before improvement
• Offer prophylaxis after withdrawal period
• Follow-up at 4-8 weeks

Key Points Summary

✓ Red flags (SNOOP4) mandate urgent investigation - thunderclap headache = SAH until proven otherwise
✓ Acute migraine: Triptan + NSAID/paracetamol first-line (avoid opioids)
✓ MOH criteria: Headache ≥15 days/month + overuse >3 months (triptans ≥10 days/month, simple analgesics ≥15 days/month)
✓ Prophylaxis if ≥2 attacks/month: topiramate/propranolol/amitriptyline for 3-month trial each
✓ Topiramate is teratogenic - ensure effective contraception in women of childbearing age
✓ Cluster headache triad: Unilateral periorbital pain + autonomic features + circadian pattern (15-180 min duration)
✓ New headache >50 years = temporal arteritis until proven otherwise (check ESR/CRP urgently)