Headaches are a very common presentation with a large number of differential diagnoses.


Differential Diagnosis

  • Tension headaches
  • Migraines
  • Cluster headaches
  • Secondary headaches
  • Sinusitis
  • Giant cell arteritis
  • Glaucoma
  • Intracranial haemorrhage
  • Subarachnoid haemorrhage
  • Analgesic headache
  • Hormonal headache
  • Cervical spondylosis
  • Trigeminal neuralgia
  • Raised intracranial pressure (brain tumours)
  • Meningitis
  • Encephalitis


Red Flags

It is important to consider red flags for serious conditions (such as raised intracranial pressure and intracranial haemorrhage) when taking a history and managing a patient with a headache. The NICE Clinical Knowledge Summaries on headache have a good summary of how to assess a headache. This is not an exhaustive list but includes the key symptoms to look out for:

  • Fever, photophobia or neck stiffness (meningitis or encephalitis)
  • New neurological symptoms (haemorrhage, malignancy or stroke)
  • Dizziness (stroke)
  • Visual disturbance (temporal arteritis or glaucoma)
  • Sudden onset occipital headache (subarachnoid haemorrhage)
  • Worse on coughing or straining (raised intracranial pressure)
  • Postural, worse on standing, lying or bending over (raised intracranial pressure)
  • Severe enough to wake the patient from sleep
  • Vomiting (raised intracranial pressure or carbon monoxide poisoning)
  • History of trauma (intracranial haemorrhage)
  • Pregnancy (pre-eclampsia)


Fundoscopy examination to look for papilloedema is an important part of an assessment of a headache. Papilloedema indicates raised intracranial pressure, which may be due to a brain tumour, benign intracranial hypertension or an intracranial bleed.

TOM TIP: Practice asking red flag questions so you can demonstrate in an exam that you are thinking about serious causes. This will score extra points and also help you document well when you start seeing patients.


Tension Headaches

Tension headaches are very common. Classically they produce a mild ache across the forehead and in a band-like pattern around the head. This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles. Tension headaches comes on and resolve gradually and don’t produce visual changes.


  • Stress
  • Depression
  • Alcohol
  • Skipping meals
  • Dehydration



  • Reassurance
  • Basic analgesia
  • Relaxation techniques
  • Hot towels to local area


Secondary Headaches

Secondary headaches give a similar presentation to a tension headache but with a clear cause. They produce a non-specific headache secondary to:

  • Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
  • Alcohol
  • Head injury
  • Carbon monoxide poisoning



Sinusitis causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses. This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the affected sinus, which helps to establish the diagnosis.

Sinusitis usually resolves within 2-3 weeks. Most sinusitis is viral. Nasal irrigation with saline can be helpful. Prolonged symptoms can be treated with steroid nasal spray. Antibiotics are occasionally required.


Analgesic Headache

An analgesic headache is a headache caused by long term analgesia use. It gives similar non-specific features to a tension headache. They are secondary to continuous or excessive use of analgesia. Withdrawal of analgesia important in treating the headache, although this can be challenging in patients with long term pain and those that believe the analgesia is necessary to treat the headache.


Hormonal Headache

Hormonal headaches are related to oestrogen. The produce a generic, non-specific, tension-like headache. They tend to be related to low oestrogen:

  • Two days before and first three days of the menstrual period
  • Around the menopause
  • Pregnancy. It is worse in the first few weeks and improves in the last 6 months. Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.


The oral contraceptive pill can improve hormonal headaches.


Cervical Spondylosis

Cervical spondylosis is a common condition caused by degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. However, if often presents with headache.

It is important to exclude other causes of neck pain such as inflammation, malignancy and infection. It is also important to exclude spinal cord or nerve root lesions.


Trigeminal Neuralgia

The trigeminal nerve is made up of three branches:

  • Ophthalmic (V1)
  • Maxillary (V2)
  • Mandibular (V3)

Trigeminal neuralgia can affect any combination of the branches. The cause is unclear but it is thought to be caused by compression of the nerve. 90% of cases are unilateral, 10% are bilateral. Around 5-10% of people with multiple sclerosis have trigeminal neuralgia.

It presents with intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours. It is often described as an electricity-like shooting pain. Attacks often worsen over time.

There are a number of possible triggers for the pain in patients with trigeminal neuralgia. These include things like cold weather, spicy food, caffeine and citrus fruits.



NICE recommend carbamazepine as first-line for trigeminal neuralgia. Surgery to decompress or intentionally damage the trigeminal nerve is an option.


Last updated April 2019
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