Neurology: Headache and Facial Pain

• Basics: Approach to Headache
• Migraine: Migraine | Treating a Migraine Attack | Preventing Migraine | Migraine in Women
• Other primary headaches: Tension-type Headache | Medication Overuse Headache | Cluster Headache | Other Trigeminal Autonomic Cephalalgias | Other Primary Headaches
• Facial pain and pressure headaches: Trigeminal Neuralgia | Idiopathic Intracranial Hypertension | Low-pressure Headache | Other Secondary Headaches
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🤕 Headache is the commonest neurological symptom. More than 9 in 10 headaches are primary (migraine, tension-type, cluster), and most can be diagnosed from the history alone. The skill is spotting the few that are secondary and dangerous, and treating the primary ones well - including avoiding medication overuse. Thunderclap and other acute dangerous headaches are covered in the Neurological Emergencies and Stroke chapters.
Your four questions for every patient: Are there red flags for a secondary cause? What pattern is this (migraine, tension, cluster, overuse)? How often do attacks happen, and how many days a month are painkillers taken? Is prevention needed?

Approach to Headache

The history is the key test. Ask about:

• Onset - sudden (seconds) or gradual?
• Pattern - attacks with normal periods in between, or constant? How many days a month?
• Site, character and duration of attacks.
• Associated features - nausea, light and sound sensitivity, aura, eye watering, visual symptoms.
• Triggers, and what relieves it.
• Medication use - what, how often (painkiller days per month).
• Family history; impact on life; a headache diary.

Red flags for a secondary cause - need urgent assessment or imaging:

• Thunderclap headache (peak within 1 minute) - subarachnoid haemorrhage until proven otherwise.
• New headache over 50 (GCA, tumour, subdural).
• Headache with fever, neck stiffness or rash.
• Progressive headache, worse on lying down or with coughing or straining, with vomiting.
• New neurological signs, confusion, personality change, or seizures.
• Papilloedema.
• Headache triggered by exertion or sex (first episode).
• Headache that changes with posture (high or low pressure).
• Cancer, HIV or immunosuppression.
• Pregnancy or postpartum (pre-eclampsia, venous sinus thrombosis).
• Recent head injury; anticoagulants.
• Jaw claudication or visual loss (GCA).

💡 Clinical Pearl: Brain tumours rarely present with headache alone - most also have neurological signs, seizures or cognitive change. Scanning everyone with a typical primary headache causes harm from incidental findings.

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Migraine

What it is: A common inherited brain disorder causing recurrent disabling attacks. It affects about 1 in 7 people - 3 times more women than men - and is most common between 20 and 50.

Migraine without aura - attacks lasting 4–72 hours, with at least 2 of:

• One-sided.
• Throbbing.
• Moderate to severe.
• Worse with routine activity.

Plus at least one of:

• Nausea or vomiting.
• Sensitivity to light and sound.

Migraine with aura (about 1 in 3):

• Reversible neurological symptoms that spread gradually over at least 5 minutes and last up to 60 minutes. Usually followed by headache (but not always).
• Visual (most common) - zigzag lines, shimmering, a spreading blind spot (fortification spectra).
• Sensory - tingling spreading up the arm to the face.
• Speech disturbance.
• Aura is "positive" (flashing, tingling) and spreads. A TIA is usually sudden and "negative" (loss of vision or power).

Triggers:

• Stress (or relaxation after stress).
• Poor or changed sleep.
• Missed meals; dehydration.
• Menstruation.
• Alcohol.
• Bright light.

Chronic migraine: Headache on 15 or more days a month for over 3 months, with migraine features on at least 8 of them.

Variants:

• Vestibular migraine - episodic vertigo with migraine features; a common cause of recurrent dizziness.
• Hemiplegic migraine - weakness as part of the aura (rare; can be familial). Avoid triptans.
• Migraine with brainstem aura - vertigo, double vision, ataxia.
• Retinal migraine - monocular visual loss (exclude other causes).
• Children: abdominal migraine, cyclical vomiting.

Examination is normal. Imaging is not needed for typical migraine.

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Treating a Migraine Attack

Principles: Treat early in the attack (at the start of the headache, not during aura) with adequate doses.

• First line (NICE CG150):
  • Triptan plus an NSAID, or triptan plus paracetamol.
  • Or for mild attacks: NSAID (e.g. ibuprofen 400–600 mg, aspirin 900 mg) or paracetamol 1 g.
• Triptans:
  • E.g. sumatriptan 50–100 mg, rizatriptan, zolmitriptan.
  • If one triptan doesn't work, try others - response varies.
  • Vomiting: Nasal sumatriptan or zolmitriptan, or subcutaneous sumatriptan 6 mg.
  • Avoid in ischaemic heart disease, previous stroke, peripheral arterial disease, uncontrolled hypertension, and hemiplegic migraine.
  • Side effects: chest tightness, tingling, flushing.
• Antiemetics: Metoclopramide 10 mg or prochlorperazine - they help nausea and also absorption of other drugs.
• Gepants (CGRP receptor blockers, tablets):
  • Rimegepant is recommended by NICE for acute attacks when at least 2 triptans have failed, or triptans are unsuitable and NSAIDs and paracetamol haven't worked (TA919).
  • They don't constrict blood vessels, so they can be used in people with cardiovascular disease.
• Avoid opioids (including codeine) - they work poorly, worsen nausea and cause medication overuse headache.
• Limit: Triptans on fewer than 10 days a month; simple painkillers on fewer than 15 days a month.

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Preventing Migraine

When to offer prevention:

• 4 or more migraine days a month.
• Disabling attacks despite good acute treatment.
• Risk of medication overuse.

First-line preventives (NICE and BASH guidance) - start low, increase slowly, and try each for at least 8–12 weeks at a good dose:

• Propranolol 80–160 mg daily (modified-release). Avoid in asthma.
• Amitriptyline 10 mg at night, increasing to 25–75 mg (off-label) - also helps sleep and tension-type headache.
• Topiramate 25 mg, increasing to 50 mg twice daily:
  • Side effects: tingling, weight loss, word-finding difficulty, mood change, kidney stones.
  • MHRA 2024: Teratogenic - a pregnancy prevention programme applies to women who could become pregnant. It also reduces the effect of hormonal contraception.
• Candesartan 16 mg daily (off-label) - useful if BP is high.
• Other options: Riboflavin 400 mg daily; acupuncture (up to 10 sessions); flunarizine (specialist).

When 3 preventives have failed (specialist):

• CGRP monoclonal antibodies (monthly or quarterly injections) - erenumab, fremanezumab, galcanezumab, and IV eptinezumab:
  • For people with 4 or more migraine days a month.
  • Stop if migraine days are not reduced by at least 50% (episodic) or 30% (chronic) after 12 weeks.
  • Side effects: constipation (erenumab), injection-site reactions.
• Gepants for prevention - rimegepant (TA906) and atogepant (TA973) tablets.
• Botulinum toxin A (NICE TA260) - for chronic migraine (15 or more headache days a month) after 3 preventives have failed, once medication overuse is managed.
• Greater occipital nerve blocks.

Lifestyle measures for everyone:

• Regular sleep, meals, hydration and exercise.
• Limit caffeine.
• Manage stress.
• A headache diary to track triggers and response.

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Migraine in Women

• Combined hormonal contraception:
  • Contraindicated in migraine with aura (UKMEC 4 - increased ischaemic stroke risk).
  • Use progestogen-only methods, an IUD or the copper coil.
  • The progestogen-only pill (desogestrel) can reduce menstrual migraine.
• Menstrual migraine (attacks from 2 days before to 3 days after the start of bleeding):
  • Usual acute treatment.
  • If periods are predictable - perimenstrual prevention with frovatriptan (2.5 mg twice daily) or zolmitriptan (2.5 mg two or three times daily) on the days migraine is expected (NICE), or an NSAID such as mefenamic acid.
• Pregnancy:
  • Migraine often improves (especially without aura).
  • Paracetamol first; sumatriptan can be used if needed (reassuring safety data); avoid NSAIDs in the third trimester.
  • Prevention: Propranolol or amitriptyline. Avoid topiramate, valproate and candesartan.
  • New or changed headache in pregnancy needs assessment - pre-eclampsia, venous sinus thrombosis, pituitary apoplexy, IIH.
• Menopause:
  • Migraine often worsens in the perimenopause.
  • HRT is not contraindicated in migraine with aura; transdermal oestrogen is preferred (stable levels, no increase in stroke risk).

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Tension-type Headache

• What it is: The commonest headache - mild to moderate, band-like or pressing on both sides.
• Features:
  • Not made worse by routine activity.
  • No nausea; may have mild light or sound sensitivity (not both).
  • Lasts 30 minutes to 7 days.
  • Episodic (fewer than 15 days a month) or chronic (15 or more).
• Treatment:
  • Acute: Paracetamol, aspirin or an NSAID - on fewer than 15 days a month. Avoid opioids.
  • Chronic:
    • Up to 10 sessions of acupuncture (NICE).
    • Amitriptyline (off-label).
    • Exercise; physiotherapy; stress management and CBT.
• Many people with "tension headaches" actually have migraine - check for migraine features.

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Medication Overuse Headache

What it is: Headache on 15 or more days a month in someone with a pre-existing headache disorder, caused by regular overuse of acute treatments for more than 3 months:

• Simple painkillers (paracetamol, NSAIDs) on 15 or more days a month, or
• Triptans, opioids or combination painkillers (e.g. co-codamol) on 10 or more days a month.

It affects about 1 in 50 adults, and is a common reason why chronic headache doesn't respond to treatment.

Treatment:

• Explain the cause clearly - patients often fear stopping their painkillers.
• Stop the overused medicines:
  • Simple painkillers and triptans: stop abruptly for at least 1 month.
  • Opioids: withdraw gradually.
• Warn that headaches usually get worse for 1–2 weeks before improving.
• Start a preventive for the underlying migraine or tension-type headache.
• Review after 4–8 weeks. Specialist help (or inpatient withdrawal) is needed for complex cases, including high opioid use.
• Prevention: Advise all people with headache to limit acute treatment days.

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Cluster Headache

What it is: One of the most painful conditions known. It is a "trigeminal autonomic cephalalgia" (TAC).

Who gets it:

• Men more than women (about 3:1), usually aged 20–40.
• Often smokers.

Features:

• Excruciating one-sided pain around the eye or temple, lasting 15–180 minutes.
• Up to 8 attacks a day, often at the same time each day (often waking the patient at night).
• Same-side autonomic features:
  • Red, watering eye.
  • Blocked or runny nostril.
  • Drooping eyelid and small pupil (Horner's).
  • Facial sweating.
• Restlessness - the patient paces or rocks (unlike migraine, where they lie still).
• Episodic - "clusters" of daily attacks for weeks to months, then remission for months or years. About 1 in 10 have chronic cluster headache (no remission).
• Alcohol triggers attacks during a cluster.

Investigation: MRI brain (with pituitary views) for a first presentation - structural lesions can mimic it.

Acute treatment (NICE CG150):

• 100% oxygen at 12–15 L/min through a non-rebreathing mask for 15–20 minutes - arrange home oxygen.
• Subcutaneous sumatriptan 6 mg or nasal zolmitriptan 5 mg (tablets act too slowly).
• Avoid paracetamol, NSAIDs and opioids - they don't work.

Prevention (start early in a cluster):

• Verapamil - usually 240–960 mg daily (specialist titration). Needs ECG monitoring - heart block, bradycardia.
• Short course of prednisolone or a greater occipital nerve block as a "bridge" while verapamil takes effect.
• Lithium, topiramate (specialist).
• Neuromodulation for chronic cluster.
• Stop smoking.

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Other Trigeminal Autonomic Cephalalgias

💡 Clinical Pearl: A complete response to indometacin (with PPI protection) confirms paroxysmal hemicrania or hemicrania continua.

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Other Primary Headaches

• Primary stabbing headache: Very brief "ice-pick" jabs; common in migraine sufferers; benign.
• Primary cough headache: Sudden headache with coughing or straining. The first episode needs MRI - about 4 in 10 have a structural cause (especially Chiari malformation). Indometacin if primary.
• Primary exercise headache: Throbbing headache with exertion. The first episode needs investigation to exclude SAH, dissection and cardiac ischaemia ("cardiac cephalalgia").
• Headache associated with sexual activity: Explosive headache at orgasm. The first episode is investigated as thunderclap (SAH, reversible cerebral vasoconstriction syndrome).
• Reversible cerebral vasoconstriction syndrome (RCVS):
  • Recurrent thunderclap headaches over days to weeks.
  • Triggers: postpartum, serotonergic and vasoactive drugs (SSRIs, triptans, cannabis, cocaine).
  • Narrowed arteries on angiography; risk of stroke and bleeding.
  • Stop triggers; nimodipine.
• Hypnic headache: Headache that wakes older people at the same time each night. Caffeine at bedtime helps; lithium or indometacin.
• New daily persistent headache: A daily headache that starts on a clearly remembered day and doesn't go away. Exclude secondary causes (e.g. low CSF pressure, venous sinus thrombosis).

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Trigeminal Neuralgia

What it is: Severe, brief, electric-shock-like pain in one or more branches of the trigeminal nerve (usually V2 or V3 - cheek, jaw, teeth). It is usually caused by a blood vessel pressing on the nerve root.

Features:

• Attacks last seconds to 2 minutes, often in rapid succession.
• Triggered by light touch, chewing, talking, brushing teeth, shaving or cold wind.
• Usually over 50; commoner in women.
• Often misdiagnosed as dental pain - patients may have had unnecessary extractions.

Red flags - suggest secondary trigeminal neuralgia (MS, tumour); need MRI:

• Sensory loss or other cranial nerve signs.
• Age under 40.
• Pain on both sides.
• Previous optic neuritis or other MS symptoms.
• Deafness or ear problems.
• History of cancer.

Treatment:

• Carbamazepine first line - start 100 mg once or twice daily and increase gradually (often to 200 mg three to four times daily).
  • Side effects: dizziness, ataxia, low sodium, rash (HLA-B*1502 in people of Han Chinese and Thai descent - risk of Stevens–Johnson syndrome).
  • Enzyme inducer - interacts with the pill, warfarin and many other drugs.
• Oxcarbazepine as an alternative. Lamotrigine, baclofen, gabapentin, pregabalin as add-ons (specialist).
• Refer if drugs fail or aren't tolerated.
• Procedures:
  • Microvascular decompression (surgery to move the vessel off the nerve - the best long-term relief in fit patients).
  • Stereotactic radiosurgery (gamma knife).
  • Percutaneous procedures (balloon compression, glycerol, radiofrequency) - numbness afterwards.
• Acute severe exacerbation (can't eat or drink): admit for IV fluids and specialist treatment (e.g. IV fosphenytoin or lidocaine).

Other facial pain:

• Post-herpetic neuralgia - after shingles (V1). Amitriptyline, gabapentinoids, lidocaine plasters.
• Persistent idiopathic facial pain - dull, poorly localised daily pain. Tricyclics; avoid dental procedures.
• Temporomandibular disorder - jaw clicking, pain on chewing.
• Glossopharyngeal neuralgia - throat and ear pain on swallowing.

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Idiopathic Intracranial Hypertension

What it is: Raised pressure in the skull with no tumour or other cause.

Who gets it:

• Mostly women of childbearing age with obesity, especially after recent weight gain.
• It can threaten vision.

Features:

• Headache - daily, often worse in the morning and when lying down or straining.
• Transient visual obscurations - vision blacks out for seconds on standing or bending.
• Pulsatile tinnitus (a whooshing noise in time with the heartbeat).
• Double vision - sixth nerve palsy.
• Papilloedema - the key sign; visual field loss (enlarged blind spot, peripheral constriction).

Causes and associations:

• Obesity.
• Drugs - tetracyclines (doxycycline, minocycline), retinoids (isotretinoin), lithium, growth hormone, steroid withdrawal.
• Polycystic ovary syndrome.
• Sleep apnoea.

Diagnosis (UK IIH consensus guideline):

• Urgent MRI brain with MR venography to exclude a mass and venous sinus thrombosis.
• Lumbar puncture - opening pressure over 25 cm H₂O with normal CSF contents.
• Eye assessment - visual acuity, fields and optic disc photographs (ophthalmology).

Treatment:

• Weight loss - the only disease-modifying treatment. Aim for about 15% of body weight; this often brings remission. Use weight management programmes, GLP-1 receptor agonists, or bariatric surgery.
• Acetazolamide - lowers CSF production (side effects: tingling, fatigue, taste change, kidney stones).
• Topiramate - helps headache and weight (pregnancy prevention programme).
• Treat headache (often migraine-like); avoid medication overuse.
• Fulminant IIH (rapid visual loss): Urgent surgery - CSF shunt or venous sinus stenting, sometimes with temporary lumbar drains. Repeated LPs are not a long-term treatment.
• Regular eye monitoring is essential - vision loss can be permanent.

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Low-pressure Headache

• Spontaneous intracranial hypotension: A CSF leak (often from a spinal dural tear or CSF–venous fistula) lowers pressure.
  • Orthostatic headache - worse within minutes of sitting or standing, eased by lying flat; often worse later in the day.
  • Neck pain, tinnitus, muffled hearing, nausea.
  • Linked to connective tissue disorders (e.g. Ehlers–Danlos syndrome, Marfan syndrome).
• MRI with contrast:
  • Thickened enhancing meninges ("pachymeningeal enhancement").
  • "Sagging" brain.
  • Subdural fluid collections.
  • Engorged venous sinuses.
• Treatment:
  • Lie flat; fluids; caffeine.
  • Epidural blood patch (targeted or non-targeted).
  • Surgical repair of the leak.
• Post-dural puncture headache - after LP or accidental puncture at epidural (see the Localisation and Investigations chapter).
• Over-drainage of a CSF shunt causes similar symptoms.

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Other Secondary Headaches

• Giant cell arteritis - new headache over 50 with scalp tenderness, jaw claudication and visual symptoms. Same-day steroids (see the Neurological Emergencies chapter).
• Brain tumour - progressive headache, worse lying down or in the morning, with vomiting, seizures, focal signs or personality change.
• Chronic subdural haematoma - older people, anticoagulants, alcohol, falls (often forgotten). Fluctuating confusion and headache.
• Venous sinus thrombosis - progressive headache with papilloedema or seizures; pregnancy, the pill, dehydration (see the Stroke chapter).
• Colloid cyst of the third ventricle - rare; sudden headache with posture changes; risk of sudden death (hydrocephalus).
• Chiari malformation - cough-induced occipital headache; downbeat nystagmus.
• Sinusitis - facial pain with blocked nose and discoloured discharge. "Sinus headache" without nasal symptoms is usually migraine.
• Cervicogenic headache - from the neck; one-sided, worse with neck movement.
• Occipital neuralgia - shooting pain over the back of the head; tender occipital nerve; nerve block helps.
• Post-traumatic headache - after head injury; often migraine-like; watch for medication overuse.
• Sleep apnoea headache - morning headache that clears within hours.
• Hypertension - only very high BP (hypertensive emergency, phaeochromocytoma) causes headache.
• Drugs - nitrates, calcium channel blockers, PDE5 inhibitors, caffeine withdrawal.
• Carbon monoxide poisoning - headache in several members of a household, better away from home (check carboxyhaemoglobin).
• Acute angle-closure glaucoma - painful red eye, haloes around lights, nausea - eye emergency.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 28-year-old woman has 6 migraine days a month without aura. Paracetamol doesn't help. She takes the combined pill.
Answer: Migraine without aura needing better acute treatment and prevention.

• Acute: triptan plus NSAID, with an antiemetic.
• Prevention: propranolol or amitriptyline. If topiramate is chosen, the pregnancy prevention programme applies and it reduces pill effectiveness.
• The combined pill can continue (no aura).
• Headache diary; review in 8–12 weeks.

2. A 45-year-old has daily headaches. He takes co-codamol 30/500 on 20 days a month.
Answer: Medication overuse headache (opioid-containing).

• Explain; withdraw codeine gradually.
• Warn that headaches may worsen for 1–2 weeks.
• Start a preventive (e.g. amitriptyline); review in 4–8 weeks.

3. A 35-year-old male smoker has 3 weeks of nightly 45-minute attacks of severe right eye pain with tearing and a blocked nostril.
Answer: Episodic cluster headache.

• Acute: 100% oxygen at 12–15 L/min and SC sumatriptan 6 mg.
• Prevention: verapamil with ECG monitoring; short prednisolone course or occipital nerve block as a bridge.
• MRI brain (first presentation); stop smoking; avoid alcohol during the cluster.

4. A 24-year-old with BMI 38 has headaches and transient visual blackouts. She has bilateral papilloedema.
Answer: Suspected IIH.

• Urgent MRI with MR venography; then LP with opening pressure.
• Urgent ophthalmology (fields, acuity).
• Weight management (target about 15% loss); acetazolamide.
• Urgent surgery if vision is deteriorating.

5. A 68-year-old woman has stabbing pain in her left cheek triggered by eating. Neurological examination is normal.
Answer: Classical trigeminal neuralgia.

• Carbamazepine 100 mg once or twice daily, increasing slowly.
• Check sodium; watch for interactions.
• MRI if atypical; refer for microvascular decompression if drugs fail.

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Key Points

• Most headaches are primary and diagnosed from the history; look for red flags for secondary causes.
• Migraine: 4–72 hours, one-sided, throbbing, worse with activity, with nausea or light and sound sensitivity.
• Aura spreads gradually over at least 5 minutes and is "positive"; TIA is sudden and "negative".
• Acute migraine: triptan plus NSAID or paracetamol, with an antiemetic. Avoid opioids.
• Prevention for 4 or more migraine days a month: propranolol, amitriptyline, topiramate (pregnancy prevention programme) or candesartan.
• After 3 preventives fail: CGRP antibodies or gepants; botulinum toxin for chronic migraine.
• Combined pill is contraindicated in migraine with aura; HRT is not.
• Medication overuse: simple painkillers on 15 or more days a month, or triptans, opioids or combinations on 10 or more. Stop them and start a preventive.
• Cluster: men, eye pain 15–180 minutes, autonomic features, restless. Oxygen and SC sumatriptan; verapamil with ECG checks.
• Indometacin-responsive: paroxysmal hemicrania and hemicrania continua.
• Trigeminal neuralgia: carbamazepine. Image if under 40, with sensory loss, or bilateral.
• IIH: young obese women, papilloedema - MRI/MRV, LP, eye monitoring, weight loss and acetazolamide.
• Orthostatic headache: think CSF leak.

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Guidelines and Further Reading

• NICE CG150: Headaches in over 12s - diagnosis and management
• British Association for the Study of Headache (BASH): National headache management system for adults
• International Classification of Headache Disorders, 3rd edition (ICHD-3)
• NICE TA260 (botulinum toxin), TA631, TA659, TA682, TA871 (CGRP antibodies), TA906 and TA919 (rimegepant), TA973 (atogepant)
• MHRA Drug Safety Update: topiramate pregnancy prevention programme (2024)
• UK consensus guidelines on idiopathic intracranial hypertension (2018)
• FSRH UK Medical Eligibility Criteria for Contraceptive Use
• The Migraine Trust; OUCH UK (cluster headache)
• BNF - for current doses

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