NeurologyTier 1Approach to a presentation

Headache and facial pain

Red flags

  • SNOOP red flags: Systemic illness/fever/malignancy/immunosuppression, Neurological deficit, Onset thunderclap/sudden, Older age (>50) at new onset, Pattern change/postural/Valsalva-triggered/Papilloedema
  • Thunderclap headache (peak intensity <1 minute) -> subarachnoid haemorrhage until excluded
  • Headache + fever + meningism -> meningitis/encephalitis
  • Headache + jaw claudication + visual disturbance in >50s -> giant cell arteritis - urgent, risk of permanent blindness
  • Headache worse lying flat/on waking/with cough -> raised ICP
  • New headache in pregnancy/postpartum with hypertension -> pre-eclampsia/eclampsia; with focal signs -> cerebral venous sinus thrombosis

Differential by mechanism

Primary headache (no underlying structural cause)
  • Migraine, tension-type headache (commonest overall, bilateral, band-like, mild-moderate), cluster headache (severe unilateral periorbital, autonomic features, circadian clustering)
  • Trigeminal autonomic cephalalgias (cluster, paroxysmal hemicrania, SUNCT/SUNA)
Secondary headache
  • Vascular: subarachnoid haemorrhage, cerebral venous sinus thrombosis, arterial dissection, giant cell arteritis
  • Raised ICP: tumour, idiopathic intracranial hypertension, hydrocephalus
  • Infective: meningitis, encephalitis, sinusitis
  • Medication overuse headache - chronic daily headache from overuse of acute analgesics/triptans
Facial pain
  • Trigeminal neuralgia - brief, electric-shock-like, unilateral, trigger zones
  • Post-herpetic neuralgia, dental/sinus pathology, temporomandibular disorder, giant cell arteritis (jaw claudication)

Focused history

  • Onset speed (thunderclap vs gradual), first vs worst vs different from usual headache
  • Location, quality, duration, periodicity (cluster - clockwork timing, seasonal)
  • Associated features - photophobia/phonophobia/nausea (migraine), autonomic signs (lacrimation, ptosis, rhinorrhoea - cluster/TACs), visual disturbance, jaw claudication, scalp tenderness (GCA)
  • Positional/Valsalva/exertional triggers
  • Medication use (acute analgesic frequency - overuse headache), recent medication changes
  • Systemic symptoms - fever, weight loss, night sweats
  • Trigeminal neuralgia - trigger zones (light touch, chewing, cold air), paroxysmal electric quality

Focused examination

  • Vital signs including BP and temperature
  • Fundoscopy for papilloedema
  • Full neurological exam - focal deficit, meningism
  • Temporal artery palpation/tenderness (GCA)
  • Visual acuity/fields (GCA, raised ICP)
  • Facial sensation and trigeminal distribution mapping if facial pain
  • Sinus tenderness, TMJ examination if relevant

Investigation strategy

  • Primary headache with typical features and normal exam - no imaging required
  • CT brain (non-contrast) urgently if thunderclap onset - if normal within 6 hours of onset and read by an experienced radiologist, sensitivity for SAH approaches 100%; LP for xanthochromia if CT negative but suspicion remains (classically timed >=12h post-onset)
  • ESR/CRP urgently if GCA suspected - do not delay starting corticosteroids for temporal artery biopsy
  • MRI brain +/- venogram if raised ICP, positional headache, or red flags persist despite normal CT
  • LP with opening pressure if idiopathic intracranial hypertension suspected (after imaging excludes mass lesion)

Management

By diagnosis
  • Migraine: see Migraine note
  • Tension-type headache: simple analgesia, address stress/posture/sleep; amitriptyline for frequent/chronic cases
  • Cluster headache: acute - high-flow 100% oxygen (15L/min via non-rebreather, 15-20 min) and/or subcutaneous sumatriptan; prophylaxis - verapamil first-line (ECG monitoring for AV block at higher doses), short corticosteroid course as a bridge
  • Trigeminal neuralgia: carbamazepine first-line; oxcarbazepine alternative; MRI to exclude vascular compression/MS plaque; microvascular decompression or ablative procedures for refractory cases
  • GCA: immediate high-dose corticosteroids (e.g. prednisolone 40-60mg) on clinical suspicion - do not wait for biopsy; temporal artery biopsy within ~1-2 weeks; urgent ophthalmology review if visual symptoms (risk of irreversible blindness)
  • Subarachnoid haemorrhage: neurosurgical/interventional referral, aneurysm securing, nimodipine for vasospasm prophylaxis
  • Idiopathic intracranial hypertension: weight loss, acetazolamide, therapeutic LP, CSF diversion/venous sinus stenting for refractory vision-threatening cases
  • Medication overuse headache: withdraw the overused acute agent (with a bridging strategy), start appropriate prophylaxis

Traps

  • Delaying corticosteroids in suspected GCA while awaiting biopsy - the biopsy remains informative for up to ~1-2 weeks after starting steroids
  • Attributing thunderclap headache to migraine without imaging/LP work-up
  • Missing medication overuse headache as the driver of "chronic daily headache" and escalating prophylaxis without addressing the overuse
  • Treating trigeminal neuralgia as dental pain, leading to unnecessary dental procedures
  • Not offering high-flow oxygen as first-line acute cluster treatment before reaching for triptans/opioids

Talk track

SNOOP red flags decide who needs imaging; typical primary headache with a normal exam needs none. Thunderclap headache is subarachnoid haemorrhage until excluded by CT +/- LP. New headache over 50 with jaw claudication or visual symptoms is GCA - treat with steroids immediately, do not wait for biopsy. Cluster headache gets high-flow oxygen acutely and verapamil for prevention; trigeminal neuralgia gets carbamazepine and an MRI to exclude vascular compression or MS.

8 of 8 sections written · drafted 2026-09-13