Headache in an adult
Most headaches are tension-type headache or migraine. A few are the first sign of meningitis, bleeding in the brain, a hypertensive emergency or pre-eclampsia. The history, the blood pressure, a look at the neck and a pregnancy test sort most of them in minutes.
- Setting: Health centre in a market town, 1 hour by road from the district hospital
- For clinical officers, nurses and doctors at first-level facilities
- Reviewed October 2026
The presentation
Rose, 38, is a primary school teacher. She has had a headache for 5 days. It is worse in the mornings, and for the last 2 days her vision has been blurred. She feels sick but has not vomited. Two years ago she was told she had high blood pressure and was given tablets, but she stopped them 3 months ago when they ran out.
| Vital sign | Value |
|---|---|
| Blood pressure | 186/118 mmHg (repeat after 5 minutes: 184/116) |
| Pulse | 88 per minute, regular |
| Breathing rate | 16 per minute |
| Temperature | 36.8 °C |
| Conscious level (AVPU) | Alert |
Tests at hand: Urine pregnancy test · Urine dipstick · Blood glucose (finger-prick) · Malaria rapid diagnostic test (RDT)
- Severe hypertension with organ damage (hypertensive emergency) Must not missStill possible
- Meningitis Must not missStill possible
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missStill possible
- Stroke or bleeding in the brain Must not missStill possible
- MalariaStill possible
- Tension-type headacheStill possible
- MigraineStill possible
- Space-occupying lesion (tumour, abscess)Less likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Is Rose an emergency? What do you check first, and what do the vital signs tell you?
Model answer
Start with the quick check: airway, breathing, circulation, conscious level, and convulsions. She is alert, talking normally and walked in. Her pulse, breathing and temperature are within the adult up-triage limits.
The blood pressure is the problem. Two readings of about 185/117 are well above 180/110. A reading this high with symptoms (headache, blurred vision) is a red flag in the WHO hypertension protocol: it may be a hypertensive emergency and needs a decision today.
Measure it properlyCheck the cuff size and repeat the reading after a few minutes' rest before acting on a single high value. Two high readings with symptoms are enough to act on.Differential now- Severe hypertension with organ damage (hypertensive emergency) Must not missLeading (moved up)
- Meningitis Must not missStill possible
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missStill possible
- Stroke or bleeding in the brain Must not missStill possible
- MalariaStill possible
- Tension-type headacheStill possible
- MigraineStill possible
- Space-occupying lesion (tumour, abscess)Less likely
- Step 2 of 7 · Ask
What do you ask to separate the dangerous causes of headache? Name the questions that change what you do.
Model answer
- Onset: sudden and the worst ever (bleeding in the brain), or gradual over days? A first or worst headache of its kind is more likely to be serious.
- Fever, stiff neck, light hurting the eyes, a rash, confusion or fits (meningitis, cerebral malaria).
- Weakness, numbness, difficulty speaking, trouble walking, or a drooping face (stroke).
- Vomiting, headache worse lying down or on waking, and weeks of worsening (raised pressure inside the head).
- Last menstrual period and whether she could be pregnant: after 20 weeks, headache and blurred vision with raised BP is severe pre-eclampsia until proved otherwise.
- Medicines, including stopped ones; alcohol; head injury; HIV and TB history; recent travel or fever in a malaria area.
- Past pattern: similar headaches before, with aura or one-sided throbbing (migraine), or a tight band without other symptoms (tension-type).
The headache came on gradually. No fever, no neck pain, no rash, no confusion. No weakness or speech problem. She has had tension headaches before, but never with blurred vision. Her periods are irregular and the last one was about 6 weeks ago. HIV negative a year ago. She has not had fever and there is little malaria in the town.
Differential now- Severe hypertension with organ damage (hypertensive emergency) Must not missLeading
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missStill possible
- Tension-type headacheStill possible
- Meningitis Must not missLess likely (moved down)
- Stroke or bleeding in the brain Must not missLess likely (moved down)
- MalariaLess likely (moved down)
- MigraineLess likely (moved down)
- Space-occupying lesion (tumour, abscess)Less likely
- Step 3 of 7 · Look
What do you examine, and why each part?
Model answer
- Conscious level and orientation: confusion with very high BP suggests hypertensive encephalopathy.
- Neck stiffness, and Kernig's sign: meningeal irritation (infection or blood).
- Skin, including palms, soles and conjunctiva, for petechiae or purpura (meningococcal disease).
- Face, arm and leg strength, speech, pupils and walking: a focal deficit means stroke or a mass.
- Fundi if you have an ophthalmoscope: haemorrhages, exudates or a swollen optic disc.
- Heart and lungs (crackles, raised neck veins) and ankles (oedema): heart strain or fluid overload.
- Abdomen: a pregnant uterus.
Rose is alert and oriented. No neck stiffness, no rash. Strength, speech, pupils and walking are normal. There is no ophthalmoscope. Chest clear, no ankle swelling. The uterus is not palpable.
Differential now- Severe hypertension with organ damage (hypertensive emergency) Must not missLeading
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missStill possible
- Tension-type headacheStill possible
- Stroke or bleeding in the brain Must not missLess likely
- MalariaLess likely
- MigraineLess likely
- Space-occupying lesion (tumour, abscess)Less likely
- Meningitis Must not missSet aside for now (moved down)
- Step 4 of 7 · Test
You have a pregnancy test, urine dipstick, glucose and a malaria RDT. Which do you use, and what would each result change?
Model answer
- Pregnancy test first: her period is late. A positive test changes the diagnosis (pre-eclampsia is possible from 20 weeks) and the choice of BP medicine.
- Urine dipstick for protein and blood: protein can mean kidney damage from high BP, or pre-eclampsia in pregnancy.
- Glucose: diabetes changes her cardiovascular risk and treatment targets.
- A malaria RDT is not needed: she has no fever and lives in a low-transmission town. Use it for any headache with fever in a malaria area.
Results: pregnancy test negative. Urine: protein 1+, no blood, no glucose. Random glucose 6.1 mmol/L.
Differential now- Severe hypertension with organ damage (hypertensive emergency) Must not missLeading
- Tension-type headacheStill possible
- Stroke or bleeding in the brain Must not missLess likely
- MigraineLess likely
- Space-occupying lesion (tumour, abscess)Less likely
- Meningitis Must not missSet aside for now
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missSet aside for now (moved down)
- MalariaSet aside for now (moved down)
- Step 5 of 7 · Do
Put it together. What is the working diagnosis, and does she need referral?
Model answer
Severe hypertension (184/116 on repeat) with headache, blurred vision and protein in the urine, in a woman who stopped her treatment. This may be a hypertensive emergency: high BP with signs of damage to the eyes, brain or kidneys.
Meningitis is very unlikely: she has none of fever, neck stiffness, altered mental state or the typical headache with fever, and the absence of all four makes bacterial meningitis much less likely. Pre-eclampsia is excluded by the negative test. A stroke is less likely with a normal neurological examination, but she still needs assessment.
The WHO protocol is clear: BP of 180/110 or higher with symptoms is referred the same day. Hypertensive emergencies are managed in hospital.
Differential now- Severe hypertension with organ damage (hypertensive emergency) Must not missLeading
- Stroke or bleeding in the brain Must not missLess likely
- Tension-type headacheLess likely (moved down)
- MigraineLess likely
- Space-occupying lesion (tumour, abscess)Less likely
- Meningitis Must not missSet aside for now
- Pre-eclampsia (if pregnant beyond 20 weeks) Must not missSet aside for now
- MalariaSet aside for now
- Step 6 of 7 · Do
What do you do before she leaves, and what could make this an immediate emergency?
Model answer
- Keep her resting and recheck the BP and conscious level while transport is arranged.
- Follow your national protocol on whether to give an oral dose of her antihypertensive before transfer. Do not try to bring the BP down fast at the health centre.
- Write a referral note: both BP readings, symptoms, the urine result, the medicine she stopped and when.
- Send her with a relative, and tell her to go straight to the hospital, not home first.
EscalateConfusion, drowsiness, a fit, new weakness or difficulty speaking, chest pain or breathlessness turn this into an immediate transfer: ABCDE, recovery position if drowsy, check glucose, and go now. - Step 7 of 7 · Ask
What do you tell Rose, and what happens after the hospital visit?
Model answer
- Stopping blood pressure tablets is the commonest reason for a crisis like this. Treatment is usually for life.
- After discharge, she returns to the health centre for the national (HEARTS) protocol: a once-daily regimen, monthly visits until controlled, and a supply that does not run out.
- Check her cardiovascular risk, and repeat the urine protein and kidney tests at follow-up.
- Less salt, no tobacco, regular physical activity.
Your blood pressure is very high and it is affecting your eyes. You need to be seen at the hospital today. Afterwards we will give you tablets that you take every day, and we will make sure you never run out.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Hypertensive emergency | BP 180/110 or higher with headache, blurred vision, confusion, breathlessness, chest pain, nausea or vomiting, or reduced urine. | Repeat the reading; refer the same day, or now if confused, fitting or breathless. Do not lower the BP fast at first-level care. |
| Bacterial meningitis | Rapid onset of fever, headache, stiff neck, light sensitivity or confusion; purple rash. | Do not wait for tests. Give the first dose of parenteral antibiotic (ceftriaxone, per national protocol) if transfer will be delayed, and refer now. |
| Severe pre-eclampsia or eclampsia | Pregnant beyond 20 weeks (or just after birth) with BP 140/90 or more and headache, blurred vision, upper abdominal pain or fits; protein in the urine. | Magnesium sulfate and BP control per the pre-eclampsia protocol; urgent transfer with a health worker. |
| Stroke or bleeding in the brain | Sudden severe headache ('worst ever'), weakness, speech difficulty, facial droop, falling conscious level. | ABCDE, check glucose, nothing by mouth, refer now. |
| Cerebral malaria | Headache with fever and confusion or fits in a malaria area. | RDT; pre-referral artesunate; treat low glucose; refer urgently. |
Decision at first-level care
Rose has severe hypertension (184/116) with headache, blurred vision and proteinuria after stopping treatment: a possible hypertensive emergency. Meningitis, stroke and pre-eclampsia are unlikely or excluded. She is referred the same day with a referral note, and returns afterwards for long-term treatment on the national protocol.
Source: WHO Guideline for the pharmacological treatment of hypertension in adults (2021); HEARTS technical package (2018); IMAI district clinician manual, volume 2 (2011).
- Tension-type headache or migraine with a typical history, normal examination and BP below 180/110: simple analgesia and advice.
- Raised BP without symptoms: confirm on a second day and start the national protocol (start the same day if 160/100 or more).
- Headache with BP 160 to 179 / 100 to 109 and no symptoms of organ damage: start treatment, recheck within days.
- Headache after a minor illness, normal examination: analgesia and review if not better in 2 to 3 days.
- BP 180/110 or higher with symptoms (the same day).
- Fever with stiff neck, rash or confusion: first antibiotic dose, then now.
- Sudden worst-ever headache, focal signs or reduced consciousness: now.
- Pregnant beyond 20 weeks with raised BP and headache or visual symptoms: after magnesium sulfate, now.
- Headache that is new, progressive over weeks, worse lying down, or in a person with HIV.
Key learning points
- Ask about onset: a sudden, worst-ever or first-of-its-kind headache is more likely to be serious.
- Measure BP properly in every adult with headache; 180/110 or higher with symptoms is a same-day referral.
- Fever, neck stiffness, headache and altered mental state point to meningitis; when none is present, bacterial meningitis is much less likely.
- Ask every woman of childbearing age about pregnancy: headache with raised BP after 20 weeks is severe pre-eclampsia until proved otherwise.
- Stopped medicines are a common cause of hypertensive crises: plan the long-term supply as carefully as the referral.
Sources
- World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. 2021. Diagnosis on repeated readings; BP thresholds; as summarised in the hypertension protocol (red flag 180/110 with symptoms).
- World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018. Referral of BP 180/110 or higher with symptoms; protocol-based long-term treatment and follow-up.
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 2. 2011. Section 10.10b, headaches: history and examination, first or worst headache, meningeal signs, severe hypertension (BP above 180/110), severe pre-eclampsia, stroke.
- World Health Organization. WHO guidelines on meningitis diagnosis, treatment and care. 2025 (ISBN 9789240108042). Clinical features of acute meningitis; absence of all four reduces the probability of bacterial meningitis; parenteral antibiotics before transfer when a delay is likely; ceftriaxone or cefotaxime.
- World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017. Pre-eclampsia after 20 weeks; severe features (headache, visual disturbance).