Headache in OPD
Screen every headache with SNOOP. No red flags and a normal exam? Treat migraine or tension headache and look for painkiller overuse.
A 29-year-old teacher has headaches about 4 times a month for 3 years: one-sided, throbbing, with nausea and light sensitivity, lasting most of a day. Sometimes she sees zigzag lines for 20 minutes before. Over the last 6 months the headaches have become almost daily. She takes paracetamol or a "Panadol Extra" or ibuprofen on about 18 days each month. Neurological examination and fundi are normal, BP 118/76. She takes the combined pill.
What is the diagnosis, what is making it worse, and what do you change today?
- Screen for red flags firstSNOOP: systemic, neurological, sudden onset, older age, pattern change. Any one means "not a simple headache".
- Thunderclap, fever with stiff neck, or neuro signsEmergency pathway, not OPD. See headache in the ER.
- Name the headacheMigraine, tension-type, cluster or medication overuse.
- Count painkiller days15 or more days a month (10 for triptans or codeine) suggests medication overuse.
- ExamineBP, temperature, neurology, fundi, temporal arteries if over 50.
- Acute treatmentNSAID or aspirin with an antiemetic. Add a triptan for migraine.
- Prevention if frequentPropranolol or amitriptyline.
- Headache diary and follow-upTriggers, days, drugs, response.
- Thunderclap onset (worst within 5 minutes)
- Fever with neck stiffness or rash
- New weakness, fits, confusion, papilloedema
- New headache over 50, especially with jaw pain or scalp tenderness
- Pregnant or postpartum with headache and high BP
- Headache worse lying down or on coughing, with vomiting
- Subarachnoid haemorrhage
- Meningitis or encephalitis
- Raised intracranial pressure (tumour, idiopathic intracranial hypertension)
- Giant cell arteritis
- Venous sinus thrombosis
- Pre-eclampsia
- Carbon monoxide poisoning
- Medication-overuse headache
| Migraine prophylaxis | 4 or more disabling attacks a month, or attacks not responding to acute treatment |
| Medication overuse | Simple analgesics on 15 or more days a month, or triptans, codeine or combinations on 10 or more |
| Sumatriptan | 50–100 mg orally at onset, repeat after 2 hours if it returns (max 300 mg a day) |
| Ibuprofen | 400–600 mg at onset |
| Aspirin | 900 mg at onset (adults) |
| Propranolol | 40 mg twice daily, up to 80 mg twice daily |
| Amitriptyline | 10 mg at night, increasing by 10 mg every 2 weeks to 25–50 mg |
| Migraine with aura | Avoid the combined pill |
Check every dose against a current drug reference and your hospital protocol.
On this page
Red flags: SNOOP
| Letter | Red flag | What it suggests |
|---|---|---|
| S | Systemic: fever, weight loss, cancer, HIV, immunosuppression | Infection, metastases |
| N | Neurological signs, fits, confusion, papilloedema | Mass, bleed, infection, raised pressure |
| O | Onset sudden (thunderclap: worst within 5 minutes) | Subarachnoid haemorrhage |
| O | Older: new headache over 50 | Giant cell arteritis, mass |
| P | Pattern change, positional, worse on coughing or straining, pregnancy or postpartum | Raised pressure, venous thrombosis, pre-eclampsia |
Any red flag: see headache in the ER.
History
- Onset and timing: when did it start? Sudden or gradual? How long do attacks last? How often?
- Site and character: one side or both? Throbbing, pressing, stabbing?
- Associated features: nausea, vomiting, light and sound sensitivity, aura (visual zigzags, numbness, speech change), red watery eye, blocked nose.
- Triggers: missed meals, poor sleep, stress, periods, bright light, caffeine changes.
- Painkillers: which, how many days a month? Codeine-containing products and "extra" combinations are common in Pakistan.
- Red flags: see SNOOP.
- Impact: missed work or study, mood, sleep.
- Women: contraception (oestrogen with aura), pregnancy plans.
Examination
- BP, temperature.
- Neurological examination: cranial nerves, limbs, gait, coordination.
- Fundi for papilloedema (dim room, dilate if needed).
- Neck stiffness.
- Over 50: tender, thickened or pulseless temporal arteries.
- Sinuses, teeth, jaw joint, neck muscles.
- Visual acuity in students and young people (refractive error).
Which headache?
- Tension-type
- Simple analgesia, lifestyle, limit days
- Migraine
- NSAID plus antiemetic, triptan, prophylaxis if frequent
- Cluster headache
- 100% oxygen, sumatriptan injection, specialist
- Medication overuse
- Stop the overused drug, start prophylaxis
| Type | Features |
|---|---|
| Tension-type | Band-like, both sides, pressing, mild to moderate, no nausea, not worse with activity |
| Migraine without aura | One-sided, throbbing, moderate to severe, nausea, light and sound sensitivity, worse with activity, 4–72 hours |
| Migraine with aura | As above, with visual or sensory symptoms for 5–60 minutes before |
| Cluster | Severe around one eye, red watery eye, drooping eyelid, restless, 15–180 minutes, mostly men |
| Medication overuse | Daily or near-daily headache, frequent painkillers |
| Sinusitis | Facial pain, blocked nose, after a cold |
| Refractive error | Students, after reading or screens, eye strain |
| Raised pressure | Worse in the morning, lying down, coughing; vomiting; papilloedema |
Treating an attack
- Take earlyAt the first sign of headache, not after hours.
- Simple analgesicIbuprofen 400–600 mg, aspirin 900 mg or paracetamol 1 g.
- AntiemeticMetoclopramide or prochlorperazine; helps absorption too.
- Triptan if simple painkillers failSumatriptan 50–100 mg; can be combined with an NSAID.
- Rest in a dark, quiet roomFluids, sleep.
Prevention
Consider prevention when attacks are 4 or more a month, disabling, or not helped by acute treatment.
| Drug | Dose | Notes |
|---|---|---|
| Propranolol | 40 mg twice daily, up to 80 mg twice daily | Avoid in asthma, heart block, depression |
| Amitriptyline | 10 mg at night, increase slowly to 25–50 mg | Helps sleep and tension-type too; drowsiness, dry mouth |
| Topiramate | 25 mg at night, increase slowly | Avoid in pregnancy; reduces effectiveness of the pill |
| Flunarizine | 5–10 mg at night | Used in some centres; weight gain, low mood |
- Give each drug 2–3 months at a good dose before deciding it hasn't worked.
- Keep a headache diary to measure response.
Medication-overuse headache
- Simple painkillers on 15 or more days a month, or triptans, codeine or combination painkillers on 10 or more days, for over 3 months.
- Stop the overused drug (simple painkillers and triptans abruptly; codeine may need tapering).
- Warn that headaches get worse for 1–2 weeks before they improve.
- Start prophylaxis at the same time (amitriptyline or propranolol).
- Limit acute treatment to 2–3 days a week from then on.
Special groups
- Migraine with aura and the combined pill: stroke risk rises; switch to a progestogen-only method.
- Pregnancy: paracetamol first; avoid NSAIDs in the third trimester; new severe headache with high BP after 20 weeks is pre-eclampsia until proven otherwise.
- Children and students: check vision; screen time, sleep, missed meals; abdominal migraine.
- Over 50 with new headache: ESR and CRP for giant cell arteritis.
Treatment doses
Common mistakes
- Not asking about painkiller days a month.
- Prescribing codeine or more combination painkillers for daily headache.
- Missing papilloedema because the fundi weren't checked.
- Ignoring a new headache in someone over 50.
- Leaving a woman with migraine with aura on the combined pill.
- Starting prophylaxis and stopping it after 2 weeks.
Frequently asked questions
What is the best treatment for a migraine attack?
An NSAID (ibuprofen) or aspirin taken early, with an antiemetic, and a triptan such as sumatriptan if these don't work.
What causes medication-overuse headache?
Using simple painkillers on 15 or more days a month, or triptans, codeine or combination painkillers on 10 or more days a month, for over 3 months.
When is a headache dangerous?
Sudden severe onset, fever with neck stiffness, new neurological signs, new headache over 50, headache worse lying down or on coughing with vomiting, and headache in pregnancy with high BP.
Which drugs prevent migraine?
Propranolol and amitriptyline are first choices. Topiramate is an alternative. Each needs 2–3 months at a good dose.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman with migraine takes painkillers on 18 days a month and now has daily headache. What is the likely problem?
Answer: Medication-overuse headache. Simple analgesics on 15 or more days a month cause medication-overuse headache.
- Cluster headache: Different pattern.
- Sinusitis: No.
- Brain tumour: No red flags.
- Tension-type headache only: Overuse explains the change.
2. Which drug is used to prevent frequent migraine in a woman without asthma?
Answer: Propranolol. Propranolol or amitriptyline are first-line prophylaxis.
- Diazepam: No.
- Sumatriptan daily: Acute treatment, not prevention.
- Codeine: Worsens headache.
- Ibuprofen daily: Causes overuse headache.
3. A 70-year-old has a new headache with jaw pain on chewing. What is the concern?
Answer: Giant cell arteritis. Same-day ESR, CRP and steroids to protect vision.
- Tension headache: No.
- Dental abscess: Jaw claudication suggests GCA.
- Cluster headache: No.
- Migraine: New over 50 is a red flag.
4. A woman with migraine now has daily headaches; she takes paracetamol–codeine tablets on 20 days each month. What is the key management step?
Answer: Withdraw the overused analgesics. Medication overuse headache: chronic daily headache (≥ 15 days/month) in a person with a primary headache using acute medication regularly (simple analgesics ≥ 15 days/month; triptans, opioids, combination analgesics ≥ 10 days/month) for > 3 months. Management: education, withdraw overused drug (abruptly for simple analgesics/triptans; gradually for opioids), start migraine prophylaxis (topiramate, amitriptyline, propranolol); headache worsens before improving.
- Increase codeine dose: More codeine worsens overuse headache.
- Add a stronger opioid: Stronger opioids worsen it.
- Brain MRI then continue drugs: Imaging is not the main step.
5. A 28-year-old woman has recurrent unilateral throbbing headaches with nausea, photophobia and visual aura, lasting 12 hours. Paracetamol doesn’t help. What is the best acute treatment?
Answer: Triptan + NSAID. Migraine: recurrent headache (4–72 h) — unilateral, pulsating, moderate–severe, worsened by activity, with nausea/photophobia; ± aura. Acute: NSAID or aspirin, triptan (sumatriptan) ± antiemetic (metoclopramide/prochlorperazine); combination triptan + NSAID is effective. Avoid opioids. Limit acute meds to < 10 days/month to avoid medication-overuse headache. Prevention if ≥ 4 attacks/month: propranolol, amitriptyline, topiramate (teratogenic), candesartan, CGRP antibodies. Combined pill contraindicated with aura.
- Opioid (codeine): Opioids cause medication overuse and nausea.
- Ergotamine daily: Daily ergotamine causes overuse and vasospasm.
- Propranolol at onset: Propranolol is preventive, not acute.
6. A man with angina has migraine with aura. Which drug should be avoided for his acute attacks?
Answer: Sumatriptan. Triptans are 5-HT1B/1D agonists that constrict cranial vessels and also coronary arteries. They are contraindicated in ischaemic heart disease, uncontrolled hypertension, previous stroke and hemiplegic migraine. Simple analgesics plus an antiemetic are suitable alternatives.
- Paracetamol: Safe.
- Ibuprofen: Usually safe (watch other risks).
- Metoclopramide: Antiemetic; safe.
- Aspirin: Safe for migraine; also antiplatelet.
7. An elderly alcoholic on warfarin has fluctuating confusion over two weeks after a minor fall. CT shows a crescent-shaped collection crossing suture lines. Which vessels bled?
Answer: Bridging veins (subdural haematoma). Subdural haematoma: tearing of bridging veins between cortex and dural sinuses; crescent-shaped, crosses sutures; risk in elderly, alcoholics (brain atrophy) and anticoagulated patients; may be chronic with fluctuating consciousness. Extradural: middle meningeal artery after temporal fracture, lens-shaped, does not cross sutures, lucid interval.
- Middle meningeal artery: Extradural: lens-shaped.
- Berry aneurysm of the circle of Willis: Subarachnoid haemorrhage.
- Lenticulostriate arteries: Hypertensive intracerebral bleed.
- Superior sagittal sinus: Not the usual source.
References and dose sources
- NICE CG150 — Headaches in over 12s
- NICE CKS — Migraine
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Sumatriptan dosing: Drugs.com: Sumatriptan dosage (see also our sumatriptan dose page)
- Metoclopramide dosing: Drugs.com: Metoclopramide dosage (see also our metoclopramide dose page)
- Propranolol dosing: Drugs.com: Propranolol dosage (see also our propranolol dose page)
- Amitriptyline dosing: Drugs.com: Amitriptyline dosage (see also our amitriptyline dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.