Headache
SNOOP4 — Secondary Headache Red Flags
| Red flag | Likely cause | Action |
|---|---|---|
| Sudden onset — thunderclap headache (maximal in seconds) | Subarachnoid haemorrhage (SAH): ruptured intracranial aneurysm. Thunderclap without meningism can also be: reversible cerebral vasoconstriction syndrome (RCVS — recurrent thunderclap; associated with vasoactive drugs, postpartum); cerebral venous sinus thrombosis; hypertensive emergency. Key feature: speed not severity. Maximum severity within 60 seconds = thunderclap regardless of absolute severity. | 999; CT head without contrast (98% sensitive within 6h); LP if CT negative (xanthochromia on spectrophotometry) |
| New headache in age ≥50 with temporal scalp tenderness, jaw claudication, or visual symptoms | Giant cell arteritis (GCA): granulomatous vasculitis of medium-large vessels. ESR typically >50 (often >100); CRP elevated. Risk: anterior ischaemic optic neuropathy → bilateral irreversible blindness within hours. Jaw claudication (jaw ache when chewing — ischaemia of masseter) and scalp tenderness (inability to brush hair) are highly specific for GCA. Visual symptoms (amaurosis fugax, diplopia): immediate high-dose steroids. | Prednisolone 40–60mg OD immediately (visual symptoms: 60mg); ESR + CRP; same-day ophthalmology if visual loss; temporal artery biopsy within 2 weeks |
| Headache + fever + neck stiffness + photophobia ± non-blanching rash | Bacterial meningitis (Neisseria meningitidis, Streptococcus pneumoniae) or viral encephalitis. Meningococcal septicaemia: non-blanching petechial/purpuric rash = septic emboli — most dangerous. Kernig's sign (inability to extend knee with hip flexed); Brudzinski's sign (neck flexion causes knee flexion). Neck stiffness may be absent in early disease or immunocompromised. | 999; IM/IV benzylpenicillin if meningococcal rash (do NOT delay transfer); IV dexamethasone; LP after CT if stable; blood cultures; PCR |
| Headache worse in the morning, on bending, coughing, or Valsalva; associated with vomiting, progressive visual change, or new focal neurology | Raised intracranial pressure: brain tumour (primary or metastatic), subdural haematoma (chronic — especially elderly on anticoagulants; history of minor head injury weeks prior), hydrocephalus, cerebral abscess. Idiopathic intracranial hypertension (IIH): obese young women; pulsatile tinnitus; papilloedema. Subdural haematoma: fluctuating conscious level, hemiparesis; anticoagulant/fall history. | CT head (MRI if CT negative); urgent neurology/neurosurgery; fundoscopy (papilloedema); reduce anticoagulation if subdural suspected |
| Headache in pregnancy or postpartum with hypertension or visual changes | Pre-eclampsia/eclampsia: hypertension + proteinuria + headache + visual disturbance in pregnancy or up to 6 weeks postpartum. Cerebral venous sinus thrombosis (CVST): progressive headache in late pregnancy or postpartum; papilloedema; seizures; focal neurology; MRI + MRV. Postpartum headache + hypertension: treat as pre-eclampsia until proven otherwise. | Pre-eclampsia: IV labetalol/hydralazine; magnesium sulphate (eclampsia prophylaxis); 999. CVST: anticoagulation; MRI + MRV; neurology. |
| New headache in patient with known malignancy or HIV | Cerebral metastasis: most commonly from breast, lung, renal, melanoma. Raised ICP, seizures, focal neurology. Leptomeningeal carcinomatosis: headache + cranial nerve palsies + radiculopathy. Opportunistic infections in HIV: cryptococcal meningitis (India ink or cryptococcal antigen); toxoplasmosis (ring-enhancing lesions). Progressive multifocal leukoencephalopathy (PML): JC virus in low CD4 count. | CT/MRI with contrast; urgent neurology/oncology; LP if safe; HIV test if unknown status and suspected opportunistic infection |
Safeguarding Considerations in Headache
🏠 Domestic Abuse — Head Trauma
- Chronic headache in a patient with a history of domestic abuse: consider chronic traumatic injury (subdural haematoma; post-concussion syndrome; cervicogenic headache from neck injury)
- Ask about headache onset in relation to any injury; subdural haematoma may present weeks after even a minor head injury in anticoagulated patients
- Always screen for domestic abuse in women with unexplained chronic pain syndromes including chronic daily headache
- Safe enquiry: "sometimes people get headaches from falls or injuries — has anything like that happened to you?"
💊 Medication Misuse and Dependence
- Codeine: opioid; dependence risk; Rachel is taking codeine 30mg daily — assess for dependence (taking to avoid withdrawal symptoms vs pain relief)
- Codeine is available OTC in low doses; patients may be obtaining from multiple pharmacies
- Withdrawal of codeine must be supported — abrupt cessation in dependent patients can cause significant symptoms
- FRANK (0300 123 6600) and local drug and alcohol services for codeine dependence support
🧠 Mental Health and Chronic Pain
- Chronic daily headache and MOH: high comorbidity with depression (40–50%) and anxiety; bidirectional relationship
- PHQ-9 and GAD-7 at every chronic headache consultation
- Catastrophising and pain hypervigilance amplify headache disability; CBT-based approaches are evidence-based
- Sleep disruption from headache → depression → more headache → vicious cycle; sleep hygiene is a therapeutic intervention
🤰 Headache in Reproductive-Age Women
- Rachel is 32 and on the OCP: migraine with aura + OCP = absolute contraindication — act today
- Topiramate and sodium valproate: highly teratogenic; pregnancy test and highly effective contraception mandatory before prescribing in women of childbearing potential
- Migraine commonly worsens in first trimester; may improve in second/third; paracetamol is safest acute analgesic in pregnancy
- Triptans in pregnancy: limited safety data; generally avoided; sumatriptan has most data; not absolutely contraindicated but specialist input preferred
💊 The Rebound Trap
Rachel's escalating daily headaches despite increasing analgesia is a classic MOH presentation. The mechanism is counterintuitive: analgesics used more than 10–15 days per month downregulate endogenous pain modulation pathways and sensitise central pain processing, making the headache threshold lower and lower. Each dose of analgesic provides relief but the baseline pain intensity increases. This is not tolerance in the pharmacological sense — it is a neurobiological remodelling effect specific to MOH.
"The medication is not failing because your headaches are getting worse independently — the daily pain relief is actually the main thing driving the daily headaches. It sounds strange because you're in real pain, but stopping the painkillers — with support — is the treatment that gives most people their lives back."🏫 Occupational Stress as Trigger
Rachel is a teacher in a stressful term. Stress is the most common migraine trigger and a significant perpetuating factor in chronic daily headache. The relationship between stress and headache is bidirectional: stress triggers headaches; headaches create stress (workplace absences, concentration impairment, social withdrawal). Sleep disruption from headache and stress compounds both. Addressing stress is both a headache management strategy and an occupational health concern.
"Work stress is one of the most common migraine triggers. It's not all in your head — there's a real biological pathway between stress and headache. Part of the treatment plan is looking at sleep hygiene, relaxation, and whether there is support at school. Is there anything at work that we could address?"🚺 OCP and Contraception Identity
Stopping the OCP is a significant practical and emotional event. Rachel has been on Microgynon for 4 years. The OCP may be integral to her contraceptive planning, her relationship, and her identity. The GP must explain clearly why the OCP must stop (UKMEC 4 — not a risk-benefit discussion), offer concrete alternatives (progestogen-only pill — similar mechanism but without the oestrogen that drives the risk), and acknowledge that this is an additional change on top of analgesic withdrawal. The progestogen-only pill (desogestrel, Cerazette) does not worsen migraine and is not associated with stroke risk.
"I know stopping the pill is an additional thing to deal with. I want to be clear why: the zigzag before the headache is what we call an aura, and with aura the combined pill carries a significant stroke risk. But the progestogen-only pill is just as effective for contraception and doesn't carry that risk. I can prescribe that today."📱 Screen Time and Sleep
Rachel's heavy social media use and evening phone use likely contributes to poor sleep quality (blue light; cognitive arousal; delayed sleep onset). Sleep changes — particularly sleep deprivation or irregular sleep patterns — are among the most potent migraine triggers. Sleep disruption also perpetuates MOH by impairing endogenous pain modulation. Addressing sleep hygiene is both a migraine management strategy and an important wellbeing intervention. The message: consistent sleep-wake times; screens off 60 minutes before sleep; sleep at the same time every day (including weekends).
"The phone in the evenings is probably affecting your sleep more than you realise, and poor sleep is one of the strongest migraine triggers. Consistent sleep — same time every night — is actually one of the most effective migraine prevention strategies. It sounds simple, but the evidence is strong."🧠 Health Anxiety About Headache
Chronic headache frequently coexists with health anxiety, particularly around brain tumour fears. Addressing this directly — not dismissing it but engaging it specifically — reduces the anxious amplification of pain perception. "I want to address the worry about something serious" — naming the fear specifically and explaining why the clinical picture does not fit tumour changes the patient's illness framework and reduces catastrophising, which is a significant driver of headache-related disability.
"I want to address the worry about something serious going on. The pattern of your headaches — daily, both sides, years of similar headaches in your mother, the visual symptoms before — this is a very recognisable picture of migraine complicated by medication overuse. This is not a brain tumour pattern. I don't think we need a scan right now, and I want to explain why."🤝 Withdrawal as Empowerment
The MOH withdrawal conversation requires framing the stopping of medication as an active treatment, not a denial of care. Rachel is in pain and wants relief. Being told to stop all painkillers feels like abandonment. The reframe: "stopping the medication IS the treatment; in 3–4 weeks, most people notice a dramatic improvement in headache frequency; the few weeks of worsening are the price of getting your life back." Peer testimony (most patients find this transformative) and a clear review plan (2 weeks) supports engagement with the withdrawal process.
"I know this is not what you came in hoping for. You came in hoping for stronger pain relief — and I'm going to ask you to stop the pain relief you are taking. That is a hard ask. But most people who go through this — and the first 10 days are genuinely worse — say that 4 weeks later they cannot believe how much better they feel. This is a treatment. I want to see you in 2 weeks."- Not asking about aura — the MOST important single question in this consultation; migraine aura determines the OCP decision
- Not asking about analgesic frequency — MOH is the primary driver of daily headaches; must be quantified
- Prescribing stronger analgesics (codeine escalation or tramadol) — worsens MOH; serious clinical error
- Continuing the combined OCP without discussing UKMEC 4 — stroke risk; absolute contraindication
999 / Same-Day Hospital
Act before completing history- Thunderclap headache — sudden onset maximal in seconds999; CT head without contrast; LP if CT negative; SAH until proven otherwise regardless of severity
- Headache + fever + non-blanching rashMeningococcal meningitis; 999; IM benzylpenicillin before transfer if rash present; do not delay transfer for LP
- New headache + focal neurology + impaired consciousness999; CT head; raised ICP, intracerebral haemorrhage, or encephalitis
- Headache + BP >180/120 + papilloedemaMalignant hypertension; IV antihypertensives in hospital; do NOT lower BP too fast (risk of watershed infarct)
- Headache in pregnancy with hypertension + proteinuriaPre-eclampsia/eclampsia; 999; IV labetalol/MgSO4; obstetric emergency
Immediate Specialist Assessment
Today- GCA with visual symptoms — age ≥50Prednisolone 60mg immediately; same-day ophthalmology; do NOT wait for ESR/biopsy
- New severe headache in immunocompromised (HIV, cancer, transplant)CT head + LP; cryptococcal meningitis; toxoplasmosis; same-day assessment
- First-ever "worst headache of life" — even if not thunderclapCT head; further assessment in A&E; do not reassure without investigation
GP Management
Primary headache — community- Migraine with aura — RachelStop OCP today; prescribe progestogen-only; MOH withdrawal plan; triptan for acute; prophylaxis if frequent; review 2–4 weeks
- Tension-type headacheLifestyle; paracetamol/ibuprofen acutely; amitriptyline if chronic (>15 days/month); stress management
- Cluster headache — new diagnosisRoutine neurology referral; prescribe O2 concentrator; subcutaneous sumatriptan; verapamil prophylaxis
- Not performing any red flag screen before treating as primary headache — even if the diagnosis appears clear, the thunderclap screen must be performed
- Not checking BP before prescribing progestogen-only pill or triptan — standard clinical assessment; triptan relatively contraindicated in uncontrolled hypertension
- Scanning Rachel without clinical indication — unnecessary; does not change management; creates scan-dependent health anxiety behaviour
- Not ordering ESR/CRP if GCA is suspected in any patient ≥50 — critical diagnostic test that must not be missed
"You have two things going on that are connected. The first is migraine — a neurological condition where your brain generates pain that is often one-sided, throbbing, with nausea and sensitivity to light, and in your case preceded by those visual zigzag shapes which are what we call an aura. Migraine is a recognised, treatable condition — and the fact that your mother has it is typical. The second thing is what we call medication overuse headache. When you take pain relief more than about 10 to 15 days in a month — which you've been doing — your brain's pain-regulating system becomes overwhelmed, and instead of working properly to modulate pain, it starts generating more pain between doses. The more you take, the more often the headaches come, the more you need — it's a trap. The way out is to stop the pain relief, with my support, and add a preventive medication instead. The first 7 to 10 days will be harder — your headaches will likely worsen before they improve. But for most people, 3 to 4 weeks later the daily headaches are gone and they get back to episodic migraines they can manage properly."
"The paracetamol isn't working any more — I need something stronger."
"I completely understand why you feel that — the medication isn't giving relief and you're in pain every day. But I have to be honest with you: stronger painkillers would make the situation worse, not better. The daily headaches are being driven by taking pain relief every day. Adding codeine-based medication would deepen the rebound cycle. The treatment that actually works is stopping all the daily pain relief — which I know sounds counterintuitive when you're in pain — and adding a preventive medication instead."
"Could you do a brain scan just to rule things out?"
"I understand why you'd want that peace of mind. The pattern of your headaches — exactly matching migraine, with the visual aura, in the same way your mother experiences them — doesn't raise any features that would make me worried about something structural. If I were worried, I'd scan you today. The guidelines say we shouldn't scan routinely for this pattern because it would be very likely to give us a normal result and not change the treatment. If anything changes — sudden onset, new weakness, or the headaches feel completely different — you should call us."
Medication Overuse Headache (Rachel)
Daily analgesics >10–15 days/month. MOH transforms episodic migraine into chronic daily headache. Withdrawal + prophylaxis = cure for most patients.
Drug-induced headache
Nitrates, PDE5 inhibitors, OCP (withdrawal in pill-free week), caffeine withdrawal, decongestants, antihypertensives. Review medication timeline.
SAH
Thunderclap; worst headache of life; sentinel headache; 999; CT; LP if negative.
GCA
Age ≥50; temporal headache; jaw claudication; visual symptoms; steroids immediately; do not wait for biopsy.
Raised ICP / IIH
Morning headache; papilloedema; progressive; obese young women; CT/MRI; LP opening pressure.
- Diagnosing only MOH without naming the underlying migraine with aura — the OCP needs to stop based on the aura, not the MOH; both diagnoses must be communicated
- Referring Rachel to neurology before any primary care treatment attempt — this is premature and not guideline-compliant; primary care treatment should be optimised first
Validate the pain before explaining the cause
Rachel is in genuine pain every day. Starting with "the analgesics are causing your headaches" before acknowledging the real suffering feels dismissive. Begin with: "I can see you've been managing this on your own for 3 months, in real pain, while teaching — that's very hard." Then explain.
"I want to say first: the headaches are real and I can see how much they've been affecting you. I'm not going to minimise that or tell you it's stress. There is a real explanation for what's happening and there is a treatment — but it's not what you were expecting."Explain MOH mechanistically — the rebound trap
The MOH explanation must be specific and mechanistic, not a vague "painkillers can cause headaches." Rachel needs to understand the neurobiological reason — otherwise she will not believe it. The analogy: "your brain's pain thermostat has been overridden by the daily painkillers; without them, the thermostat fires at a lower threshold, generating pain." Concrete and visual.
"What has happened is that your brain has become used to having pain relief in the system every day. When the painkiller wears off, the pain-signalling system in your brain fires more intensely than it should. You take more painkiller, it damps it down, but the baseline gets worse. After 3 months of daily use, the medication is the main thing driving the daily headaches."Offer a structured plan with a specific timeline
Telling someone to "stop all pain relief" without a structured plan and bridge medication is inadequate and will fail. The plan has four components: (1) stop all analgesics simultaneously; (2) bridge with naproxen or prednisolone for 2 weeks; (3) add preventive medication (amitriptyline or propranolol); (4) review at 2 weeks with headache diary. The timeline: "the next 10 days will be harder; most people see significant improvement by week 3–4."
"Here is what I want to do: stop the paracetamol and codeine completely, give you a short 2-week course of naproxen as a bridge that doesn't cause rebound, start a preventive medication to reduce how often the migraines come, and see you in 2 weeks. Most people who do this say 4 weeks later they feel dramatically better. I'll be here to support you through it."Sleep changes — both deprivation and oversleeping — are among the most potent migraine triggers. The mechanism: serotonin and other neurotransmitters involved in migraine are reset during sleep. Irregular sleep times disrupt this resetting. Weekend lie-ins are a common but under-recognised migraine trigger. Consistent wake time (even at weekends) stabilises the circadian rhythm and reduces attack frequency significantly in many patients.
Same wake time every day including weekends. Screen/phone off 60 minutes before bed (blue light inhibits melatonin; cognitive arousal delays sleep onset). Avoid caffeine after 2pm. No alcohol within 3 hours of sleep (fragments sleep architecture). Cool, dark, quiet bedroom. Consistent sleep is one of the most effective migraine prevention strategies — free, no side effects.
Skipping meals (hypoglycaemia): very common trigger; eat at regular intervals; always eat breakfast. Dehydration: 2L water minimum/day; headache often precipitated by mild dehydration. Alcohol: ethanol vasodilator + causes dehydration + contains tyramine and histamine (red wine especially). Caffeine: regular users — skipping morning coffee causes withdrawal headache; gradually reduce rather than abrupt cessation. Tyramine-rich foods: aged cheese, cured meats, fermented foods — trigger in susceptible patients; headache diary identifies individual triggers.
A headache diary prospectively identifies dietary triggers. Not all patients have food triggers — asking the patient to avoid all "migraine foods" without evidence of personal trigger is unnecessary restriction. Use the diary to identify individual patterns.
Stress is the single most commonly reported migraine trigger (reported by ~70% of migraine sufferers). Stress activates the hypothalamic-pituitary-adrenal axis, releases cortisol and catecholamines, and lowers the threshold for trigeminal pain activation. Both the acute stress (trigger) and the "let-down" after stress subsides (weekend migraine pattern after a stressful week) can trigger attacks. Addressing Rachel's work stress is both a wellbeing and a migraine management intervention.
Cognitive behavioural therapy for headache: evidence-based; shown in RCTs to reduce migraine frequency comparably to pharmacological prophylaxis; especially effective when anxiety and pain catastrophising are present. NHS Talking Therapies referral (Improving Access to Psychological Therapies): available on NHS; low-intensity CBT for headache and stress. Mindfulness-based stress reduction (MBSR): evidence for chronic pain.
Regular aerobic exercise reduces migraine frequency significantly in RCTs — comparable to topiramate in one head-to-head comparison. Mechanism: releases endogenous endorphins and endocannabinoids; reduces cortisol; improves sleep; reduces body weight (adipokines and inflammatory cytokines from adipose tissue are migraine triggers). CAUTION: vigorous sudden exercise can trigger migraine in some patients (exercise-triggered migraine); warm up gradually; pre-exercise hydration and nutrition.
Start gradually: walking → cycling → swimming → more vigorous. Pre-exercise: small snack; 500ml water; adequate warm-up. If exercise regularly triggers migraine: consider low-dose triptan pre-exercise on high-risk days. 150 minutes/week moderate intensity as a target.
Daily diary for 4–8 weeks: presence of headache (yes/no); severity (1–10); duration; features (nausea, visual symptoms, side); analgesic use (type, dose, time); potential triggers (stress level, sleep hours, meals, hydration, alcohol, period, exercise, weather); response to treatment. The diary serves dual purposes: diagnostic tool (confirms headache type and frequency; identifies MOH) and therapeutic tool (gives patients agency; identifies individual triggers; motivates lifestyle changes when patterns become visible).
Migraine Buddy, Migraine Monitor, N1-Headache: validated; free or low cost; syncs with Apple Health/Google Fit. Paper version equally effective. Ask to bring diary to every review appointment.
Stop all analgesics (paracetamol, codeine, NSAIDs) simultaneously (not one at a time — gradual withdrawal prolongs the process). Expected withdrawal period: 7–14 days of worsening headache — warn Rachel explicitly; if not warned, she will restart analgesics at day 3 when headaches peak. Bridge analgesic: naproxen 500mg BD (taken regularly, not PRN) for 2 weeks — naproxen at this duration does not cause MOH; OR prednisolone 40–50mg OD × 5 days (reduces withdrawal severity; especially useful if work commitments make severe withdrawal intolerable). Do NOT use codeine, tramadol, or triptan as bridge — all cause MOH.
Review at 2 weeks: headache diary; compliance; mood check (depression common during withdrawal; PHQ-9). Anti-emetics: domperidone or prochlorperazine for nausea during withdrawal. Letter for employer/school if significant withdrawal illness affects work attendance.
- Aspirin 900mg + metoclopramide 10mg: NICE first-line for migraine acute treatment; aspirin absorbed faster with metoclopramide (gastric stasis of migraine); efficacy equivalent to oral triptans in most patients; cheaper; no rebound at normal dosing frequency
- Ibuprofen 400mg: alternative NSAID; effective for mild-moderate attacks
- Take at onset of HEADACHE (not during aura): taking during aura does not help aura and delays absorption; take when headache begins
- MOH threshold: simple analgesics >15 days/month → MOH risk; restrict to ≤2 days/week maximum
- Sumatriptan 50–100mg oral: first-line triptan; onset 30 min; second dose at 2h if partial response; max 200mg/day. Also available: nasal spray 20mg (faster onset; useful with nausea); subcutaneous 6mg (fastest; 10 minutes; cluster headache)
- Take at onset of headache (NOT during aura) — taking during aura does not abort the headache and may reduce efficacy
- Triptan failure: try different triptan (responder profile varies); zolmitriptan, rizatriptan, eletriptan, almotriptan; try different route if oral fails (nasal, SC)
- MOH threshold: >10 days/month → triptan MOH
- Contraindications: uncontrolled hypertension; ischaemic heart disease; prior stroke/TIA; hemiplegic or basilar migraine; MAOIs; pregnancy (relative CI)
- Prednisolone 40–60mg OD: start IMMEDIATELY on clinical diagnosis of GCA; 60mg if visual symptoms (higher risk of optic neuropathy). Do NOT wait for ESR/biopsy
- Bone protection from day 1: calcium 1000mg + vitamin D 800IU; DEXA; bisphosphonate (alendronate) if T-score <-2.0; PPI (omeprazole 20mg) for GI protection
- Taper: guided by rheumatology; typical initial taper to 20mg by 3 months; total duration often 1–2 years; taper guided by symptoms and CRP/ESR
- Aspirin 75mg: some evidence for additional protection against ischaemic complications in GCA while on steroids
- Prophylaxis indications (NICE): ≥4 headache days/month significantly impacting QoL; failing to respond to adequate acute treatment; frequent use of acute medications (MOH risk); patient preference; specific subtypes (hemiplegic migraine, migraine with prolonged aura)
- Propranolol 40mg BD (up to 160mg BD): beta-blocker; first-line; evidence base; also treats hypertension and anxiety. Contraindicated: asthma, COPD, heart block, peripheral vascular disease, diabetes (masks hypoglycaemia)
- Amitriptyline 10mg nocte (titrate to 75mg): tricyclic; evidence for migraine + TTH prophylaxis; dual benefit if depression or poor sleep present; side effects: dry mouth, drowsiness, constipation, weight gain. Take at 22:00 (6–8 hours before waking)
- Topiramate 25–100mg OD: highly effective; TERATOGENIC — not in pregnancy or if not using highly effective contraception; side effects: "dopamax" (cognitive dulling, word-finding difficulties), paraesthesia, weight loss, kidney stones, metabolic acidosis; MHRA warning 2024 — mandatory contraception requirement
- Acute attack — 100% oxygen 12–15 L/min via NRB mask × 15–20 min: most effective and fastest acute treatment; prescribe home O2 concentrator (not cylinders — inadequate flow rate); onset 5–10 minutes; response rate ~70%
- Subcutaneous sumatriptan 6mg: fastest triptan route; onset 10–15 min; max 2 injections/24 hours. Nasal sumatriptan 20mg: alternative if SC not tolerated
- Oral analgesics NOT effective: too slow for 45-minute cluster attack; do not prescribe codeine or paracetamol for cluster
- Prophylaxis — verapamil SR 240–480mg/day: first-line for cluster prevention; start at onset of cluster period; titrate up; ECG monitoring (AV block risk); refer neurology for management
- Short-course prednisolone 60mg × 5 days: rapidly breaks a cluster period; bridge while verapamil reaches therapeutic level
Select headache scenario — personalised treatment recommendation
"Take the triptan at the start of the headache — not during the visual symptoms before it (the aura), because it won't work then and you'll use up your dose early. Take it as soon as the headache begins. If you get some relief in 2 hours but the headache comes back, you can take a second dose. Try not to take it more than 2 days a week — if you use it more often than that, the tablet itself can start to cause headaches. Always take an anti-nausea tablet with it if nausea is part of your migraine."
Sumatriptan: SAFE in migraine with aura (unlike combined OCP). Take at HEADACHE onset — NOT during aura. MOH threshold: >10 days/month. SC route for cluster (fastest onset). Contraindicated in ischaemic heart disease, prior stroke/TIA, hemiplegic migraine, uncontrolled hypertension, MAOIs. SSRI + triptan: caution (serotonin syndrome — not absolute CI at normal doses). Do NOT use as bridge in MOH withdrawal — it causes MOH.
"This tablet is a preventive — you take it every day regardless of headaches. It's not for the acute pain; it's to reduce how often the migraines happen. It typically takes 6–8 weeks to see the full effect, so please don't stop it before then if you don't notice a difference straight away. The most common side effect in the first few weeks is tiredness — this usually settles. Please don't stop it suddenly — come to see me first if you want to stop, because we'll need to reduce it gradually."
Propranolol: NICE first-line migraine prophylaxis. Absolutely contraindicated in asthma/COPD. Takes 8–12 weeks for full response — counsel on this. Do not stop abruptly (rebound). Dual benefit: hypertension + migraine; anxiety + migraine. Alternative if asthma/COPD: amitriptyline. Check HR before each dose increase (target HR >50 rest). Titrate gradually to effective dose (up to 160mg BD modified release).
"I want to tell you about an important requirement before I prescribe this medication. Topiramate can cause serious problems for a developing baby if you were to become pregnant while taking it — including effects on brain development. Because of this, I need to know you're using highly effective contraception — not just the pill on its own, as this medication slightly reduces how well the pill works. The best options are an implant or a coil. We'll review your contraception every year. If you're planning a pregnancy, please talk to me first — we'll switch to a different preventive medication."
Topiramate: TERATOGENIC — MHRA 2024 mandatory pregnancy prevention programme for all women of childbearing potential. DO NOT use with OCP alone (reduces OCP efficacy → pregnancy risk). Require highly effective contraception (implant, IUS). "Dopamax" cognitive side effects: word-finding, slowed thinking (dose-dependent; titrate slowly). Kidney stones: increase fluids. Metabolic acidosis: check bicarbonate. Glaucoma (rare): stop if eye pain. Do NOT use in pregnancy; switch to propranolol or amitriptyline.
"This tablet is taken at bedtime — usually around 10pm. We're using it at a low dose for headache prevention, not as a full antidepressant, though it can also help mood and sleep. The most common side effect is feeling groggy in the morning — this usually settles after 2–3 weeks. Dry mouth is common. It takes 6–8 weeks to see the preventive effect on headaches, so please give it time. Don't stop it suddenly — let me know if you want to stop and we'll taper gradually."
Amitriptyline: first-line TTH prophylaxis; also effective for migraine. Take at 22:00 (not morning — sedation used therapeutically). Titrate from 10mg; effective dose 30–75mg. Best choice when depression or poor sleep coexist with headache. Morning grogginess is most common side effect (settles in 2–3 weeks). Contraindicated in recent MI, arrhythmias, MAOIs. MHRA: QT prolongation risk at higher doses — ECG if dose >75mg. Do NOT stop abruptly.
"As soon as you feel an attack starting, put on the mask — make sure it covers your nose and mouth with no gaps — and turn the flow rate to 15 litres per minute. Sit upright leaning slightly forward. Breathe normally through the mask. Keep it on for 15 to 20 minutes — most people feel significant relief within 10 minutes. If you stop early the headache may come back. The concentrator plugs in at home; you can also use it in any room. Keep the mask and concentrator by your bed for the night attacks."
Cluster headache acute: 100% O2 12–15 L/min via non-rebreather mask (NOT nasal cannula); 15–20 minutes. Prescribe O2 CONCENTRATOR (not cylinders — insufficient volume for daily cluster attacks). ~70% response rate; onset 5–10 min. Concurrent SC sumatriptan 6mg as alternative/adjunct. Oral analgesics are INEFFECTIVE (too slow for cluster attacks). Prophylaxis: verapamil SR (ECG monitoring for AV block). Refer neurology for cluster management. COPD: O2 risk — use sumatriptan SC instead.
"I'm starting you on prednisolone today because there is a small but real risk of permanent vision loss if we wait. The steroids should prevent that. I know this is a high dose — I want to explain what we need to watch for: we'll monitor your blood pressure and blood sugars, and I'm going to prescribe a stomach-protecting tablet and calcium tablets alongside them. We'll arrange a biopsy of the temporal artery within the next 2 weeks to confirm the diagnosis. Do not stop the prednisolone without talking to me first."
GCA: prednisolone IMMEDIATELY — the most time-critical prescribing decision in all of headache medicine. Visual symptoms → 60mg (not 40mg). Never delay for ESR or biopsy. Co-prescribe from day 1: PPI + calcium/vitamin D + blood glucose monitoring plan. Long-term: DEXA + bisphosphonate; sick day rules; steroid card. Cluster bridge: 60mg × 5 days while verapamil titrates. MOH withdrawal bridge: 40mg × 5 days reduces withdrawal severity and improves analgesic cessation success rate.
Occupational Impact
Teaching requires sustained concentration, voice projection, behaviour management, and emotional regulation — all significantly impaired by daily headache and analgesic-induced cognitive dulling. Rachel's ability to function at work is being undermined both by the headaches and by the opioid analgesia (codeine causes cognitive impairment at therapeutic doses).
"I want to acknowledge that managing daily headaches while teaching is genuinely difficult — you've been doing it on your own for 3 months. The codeine makes it harder too, because it dulls concentration. Once we get through the withdrawal, your ability to think clearly at work should improve alongside the headaches."Depression and Anxiety Comorbidity
Up to 50% of patients with chronic daily headache have comorbid depression; up to 40% have significant anxiety. The relationship is bidirectional: depression lowers pain threshold; headache perpetuates depression through sleep disruption, social withdrawal, and occupational impairment. PHQ-9 and GAD-7 at every chronic headache consultation. Amitriptyline for prophylaxis has dual benefit if depression is present.
"I want to ask about your mood alongside the headaches — the two often go together, and it's not weakness to acknowledge it. How have you been feeling emotionally?"Sleep Disruption
Headaches both disrupt sleep and are worsened by poor sleep. The vicious cycle: headache → pain at night → fragmented sleep → next-day fatigue → lowered pain threshold → more headaches. Codeine at therapeutic doses disrupts sleep architecture (reduces REM sleep). Sleep hygiene intervention is both a lifestyle and a pharmacological withdrawal support measure.
"The codeine you're taking at night actually disrupts sleep — it reduces deep sleep and REM sleep, which is why you're probably not waking refreshed even when you sleep 8 hours. Part of stopping the codeine is getting your sleep quality back."Withdrawal Support and Motivation
MOH withdrawal is psychologically demanding. Rachel must get through 7–14 days of worsening headaches with the knowledge that improvement is coming — but on trust alone at that point. The GP's role is not just prescribing but providing a structured, supported withdrawal with a clear timeline, a named review date, accessible contact if severe, and validation that the plan is evidence-based and most patients succeed.
"I want to make a plan together — not just tell you what to do. Can you clear your diary for the first 2 weeks of withdrawal? If there's anything particularly important coming up at work that would make the timing impossible, we can plan around it. The goal is to give you the best chance of getting through this."Today — Stop OCP + Start Withdrawal + Start Prophylaxis
Stop combined OCP immediately; prescribe desogestrel 75mcg (Cerazette) OD or offer IUS/copper IUD. Stop paracetamol and codeine — plan simultaneous withdrawal. Prescribe naproxen 500mg BD × 14 days as bridge OR prednisolone 40mg × 5 days. Start amitriptyline 10mg nocte or propranolol 40mg BD. Warn Rachel that headaches will worsen for 7–14 days. Provide written information and Migraine Buddy app recommendation. Review in 2 weeks.
2 Weeks — Withdrawal Review
Headache diary review: frequency reducing? Withdrawal period over? Analgesic use: still abstinent from codeine/paracetamol? Naproxen bridge completed? Any severe symptoms during withdrawal (if codeine dependence: formal dependence management). PHQ-9: mood during withdrawal phase. New contraception: how is the progestogen-only pill going? Any irregular bleeding? Prophylaxis side effects (amitriptyline: morning grogginess; propranolol: fatigue).
6–8 Weeks — Prophylaxis Assessment
Headache diary: migraine frequency now; is it episodic again? Prophylaxis response: amitriptyline or propranolol at therapeutic dose — any effect? Titrate if needed. Triptan: can now be introduced for acute attacks if headaches are episodic (MOH cycle broken). Sleep quality. Occupational function. PHQ-9. Review OCP decision — any change needed?
6 Months — Prophylaxis Adequacy Assessment
Two adequate prophylactic trials? If two agents have failed at therapeutic dose for ≥3 months each: neurology referral (tertiary headache centre; CGRP antibody consideration). OCP: can she return to combined OCP if aura has fully resolved? No — migraine with aura + combined OCP remains UKMEC 4 regardless of current frequency. Review headache diary: ≥50% reduction in frequency = prophylaxis success. Consider 6-month trial of prophylaxis off (many patients can stop after sustained period of control).
Headache monitoring essentials
Headache diary: count headache days/month and analgesic use days/month at every review — the most important monitoring tool; >10–15 analgesic days/month = MOH alert. OCP: once migraine with aura confirmed, combined OCP is UKMEC 4 permanently — do not restart regardless of current aura frequency. Propranolol: HR and BP at 4–6 weeks; asthma check. Amitriptyline: PHQ-9; morning grogginess; weight; ECG if >75mg. Topiramate: annual pregnancy test + contraception review (MHRA 2024); cognitive side effects; renal function + bicarbonate; eye check (glaucoma). GCA on prednisolone: ESR/CRP; BP; blood glucose; weight; DEXA; PPI; calcium + vitamin D; steroid card; sick day rules; annual eye check; rheumatology shared care. Cluster on verapamil: ECG (AV block); BP; HR; constipation. CGRP antibody (specialist): monthly injection or quarterly; injection site reactions; blood pressure; constipation (erenumab).
⚠ Three essential safety-net conversations in headache management
Documentation requirements
- Not stopping the combined OCP — UKMEC 4 absolute contraindication; stroke risk; the most important safety intervention in this consultation
- Not identifying or explaining MOH — the primary driver of Rachel's daily headaches; must be diagnosed and addressed with withdrawal plan
- Prescribing stronger analgesics (codeine escalation, tramadol) — worsens MOH; serious clinical error
- Not addressing the aura question — missed the most important clinical finding
- Not warning about withdrawal worsening — Rachel will restart analgesics without this warning
- SNOOP4 red flags excluded before treating as primary headache
- Aura identified; OCP stopped; desogestrel prescribed (UKMEC 4)
- MOH diagnosed; mechanism explained; withdrawal plan + bridge + prophylaxis
- Topiramate: teratogenicity and contraception counselling if prescribed
- Triptan prescribed for acute attacks (after MOH withdrawal)
- Headache diary recommended; 2-week review booked
- Pain validated before withdrawal plan delivered
- ICE all three; health anxiety addressed specifically
- MOH paradox explained mechanistically, not dismissed
- OCP addressed without blame; alternative offered
- Stronger analgesic refusal explained with compassion not judgement
- 2-week withdrawal support framed as partnership
Who you are
Rachel Patel, 32, secondary school English teacher. Married with two children aged 6 and 9. You have had migraines on and off since age 18 — never formally diagnosed. Your mother has migraines. Three months ago your headaches escalated from once or twice monthly to almost daily following a very stressful start to term (new head of year role). You take paracetamol 1g + codeine 30mg on approximately 6 days out of 7 — the medication takes the edge off for 2-3 hours then the headache returns. You are on Microgynon 30 (combined OCP) for contraception, for 4 years. You use your phone heavily in the evenings and sleep 5-6 hours, irregularly. You drink approximately 10-12 units of alcohol weekly (2 glasses of wine most evenings).
Hidden details
Visual aura (critical — will NOT volunteer unless asked directly): About 20-30 minutes before most headaches, you see zigzag shimmering shapes in your vision. They move slowly across your visual field then disappear. You have had these for years and assumed they were "part of the headache." Only disclose if asked specifically: "Do you notice anything before the headache starts — like zigzag lines, flashing lights, or a blind spot in your vision?"
Brain tumour fear: Late-night Googling has made you worry about a brain tumour. You will not volunteer this unless asked what your biggest worry is. Responds very well to specific clinical explanation of why her headache pattern does not fit a tumour.
Codeine frequency: If asked carefully: "pretty much every day for 3 months — maybe 6 out of 7 days." Will admit this.
Headache details if asked
- Bilateral frontal/temporal; throbbing; moderate-severe; worsened by movement; photophobia and noise sensitivity; nausea; 4-8 hours duration if untreated
- Visual aura: zigzag shimmer, 20-30 minutes before headache (only if asked specifically)
- SNOOP4: no sudden onset; no focal neurology; no fever; no positional change; not pregnant
- No thunderclap headache; no weakness or speech problems
- OCP: Microgynon 30, 4 years; no migraine discussion at prescribing; no BP check recently
Reactions
- On aura question: "Oh — yes! I get these zigzag shimmering lines for about 20 minutes before it starts. Is that important?" Engages positively with aura explanation.
- On OCP news: Initially surprised: "So the pill could cause a stroke? I've been on it 4 years..." Accepts Cerazette if offered with clear explanation.
- On MOH explanation: Initial resistance: "But the codeine helps me get through the day..." Softens when the mechanism is explained with the brain thermostat analogy.
- On no scan: "Are you sure? I've been reading about brain tumours..." Responds well to specific clinical reasoning. "So the zigzag and my mum having it — that confirms migraine?" Yes.
- Challenge: "I've got 30 children every day — I cannot carry on like this. Can't you just give me something stronger?"
Resolution: Rachel accepts the consultation if the GP: (1) asks about visual symptoms before the headache and identifies the aura; (2) stops the combined OCP and offers desogestrel; (3) identifies MOH and explains the rebound mechanism; (4) refuses stronger analgesics with compassion and clear rationale; (5) provides a structured withdrawal plan with bridge analgesic and prophylaxis; (6) warns explicitly that headaches will worsen for 7-14 days; (7) addresses the brain tumour worry specifically; (8) books a 2-week review. Rachel disengages if stronger analgesics are prescribed, OCP is not stopped, or she is sent home without a structured plan.
- Thunderclap (maximal in seconds): SAH → 999; CT head; LP if negative
- Headache + fever + non-blanching rash: meningococcal → 999 + IM benzylpenicillin
- GCA with visual loss → prednisolone 60mg NOW + ophthalmology
- Focal neurology + headache → 999; CT head
- Malignant hypertension (BP >180/120 + papilloedema) → 999
- GCA without visual symptoms: prednisolone 40mg NOW; ESR+CRP; biopsy 2 weeks
- Raised ICP features (papilloedema, progressive, morning): CT/MRI; neurology
- New headache age ≥50: SNOOP4; ESR/CRP; exclude GCA
- Migraine + MOH: stop OCP if aura (UKMEC 4); MOH withdrawal; prophylaxis
- TTH: lifestyle; amitriptyline if chronic
- Cluster: O2 concentrator; SC sumatriptan; verapamil; neurology