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Headache is a common presenting complaint in both primary and secondary care, being the seventh most frequent presentation to primary care and one of the top three neurological causes of acute visits to the hospital. An accurate diagnosis can only be made through a comprehensive and structured approach to assessment.

This article will explore primary and secondary headaches, their diagnostic characteristics and investigations.


Headaches can be divided into primary and secondary headaches. Primary headaches lack an underlying pathological cause, such as migraine or tension-type headaches, and are by far the most prevalent. Secondary headaches are caused by underlying organic pathology, though these constitute a small minority in clinical practice. It is important to recognize any ‘red flags’ suggestive of organic pathology.

Primary headache

The most common primary headaches are tension-type headache and migraine, alongside the less common group of trigeminal autonomic cephalalgias, which includes cluster headache.

  • Tension-type headaches are usually bilateral and have a pressing/tightening character, and can range from mild to moderate in severity.
  • Migraine is usually unilateral, but may be bilateral in some cases, and is characterized by a pulsating and throbbing pain. It is usually moderate to severe, with associated features of nausea, vomiting, photophobia, and phonophobia.
  • Cluster headaches are always unilateral and have an excruciating, stabbing, or burning character. It is very severe in intensity, and commonly associated with features of restlessness, conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, and ptosis or miosis of the ipsilateral side.

All three types of primary headache typically last from 30 minutes to 7 days (or hours to days in the case of migraine).

Medication-overuse headache

Medication-overuse headache is a common problem, with high levels of morbidity in patients with primary headache conditions. It should be suspected in cases of headaches for more than 15 days per month.

Primary Headache

Primary headaches are migraine, tension-type, and cluster headaches. Medication overuse is the trigger for these headaches and may occur on 10 or more days per month. Triptans, opioids, and combination analgesics (e.g. co-codamol) can cause faster onset than simple analgesics (e.g. paracetamol).

Secondary Headache

Secondary headaches are caused by organic pathology. There are four evidence-based indicators for secondary headache: thunderclap (sudden onset) headache, associated focal neurological deficit, associated systemic features, and patients over the age of 50.

Thunderclap (sudden onset) headache

This headache is characterized by maximal intensity within one to five minutes of onset, and indicates a potential acute vascular pathology. It could be a subarachnoid haemorrhage, meningitis, or hypotensive pathology.

Associated focal neurological deficit

Symptoms may include unilateral limb weakness, cranial nerve abnormalities, or sensory deficits. This implies there may be a lesion affecting nerves, spinal, or intracerebral tracts.

Associated systemic features

Systemic features may include fever, weight loss, night sweats, and a recent-onset and progressive headache. Temporal arteritis (also known as giant cell arteritis) should be ruled out as it can cause permanent visual loss if untreated. Other differentials diagnoses include malignancy and chronic infections.

Patients over the age over 50

Headaches in patients over the age of 50 may indicate temporal arteritis.

Assessment of Headache

A rapid ABCDE assessment should be done on patients who are acutely unwell with headache. Following this, a comprehensive history and neurological examination (including cranial nerves, upper limb, lower limb, and fundoscopy) should be undertaken to detect any abnormal neurological features. Other important assessment steps include basic observations (vital signs), palpation of facial structures, and orbits examination.

Additional information is available from the British Association for the Study of Headache (BASH).

National Headache Management System

The National Headache Management System provides information for clinicians and patients on the assessment and management of headache. It is designed to be used in real-time during consultations and is derived from the 2019 British Association for the Study of Headache (BASH) Guidelines.


In a non-emergency setting, the likelihood of finding serious secondary pathology with imaging in an isolated headache with no abnormal neurology on examination is similar to people without a headache. Therefore, imaging these patients provides no clinical benefit, only exposing them to unnecessary radiation and increasing the chances of discovering incidental findings that could lead to further harm due to over investigation.

When a patient presents with a headache in association with abnormal neurology, imaging is indicated. This is notably important if a patient has a thunderclap headache, as it may be a sign of a subarachnoid haemorrhage. A CT scan is the most appropriate imaging modality to use first in this case.

Key Points

  • Most headaches are primary headaches such as migraine or tension-type headache.
  • Tension-type headache is a non-disabling, pressing, bilateral headache that lasts 30 minutes to 7 days.
  • Migraine is distinctive due to the disabling nature of attacks (ie. inability to perform activities of daily living) with associated nausea, vomiting, and photo or phonophobia.
  • Cluster headache is rare but distinguishable due to its excruciating pain.
  • Medication overuse headache can occur from using analgesia as little as 10 days per month.
  • Secondary headache indicators are thunderclap headache, associated systemic features, focal neurology, and age over 50.
  • Patients presenting with secondary headache indicators should have a CT scan.

A Guide to Keeping Healthy Joints

The health of our joints is something that often goes overlooked, when in fact it shouldn't. Joint health is essential for older people, as it can help to delay the onset of degenerative joint diseases such as osteoarthritis. Keeping our joints healthy can also improve our mobility, help us maintain an active lifestyle, and even increase our overall life expectancy.

So, how do we go about keeping our joints healthy? Here are some tips:

  • Maintain a healthy weight: Being overweight puts extra strain on our joints, which can lead to premature wear and tear.
  • Take regular exercise: Regular physical activity will help to strengthen the muscles and ligaments that support our joints.
  • Eat nutritious foods: Eating a balanced diet helps to keep joints lubricated and maintain joint cartilage.

We should also consider avoiding activities that are a risk to our joint health. This includes running on hard surfaces, jumping for long periods of time, and lifting heavy weights. Joint injury can also occur due to repetitive motions of certain activities.

Ultimately, the health of our joints is in our hands. Taking proactive steps to keep them healthy now can help us to stay active and mobile into old age.

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