Primary headaches: Migraines, tension headache
Vascular: Temporal arteritis, venous sinus thrombosis
Ophthalmic: Acute glaucoma
Medication-related: Medication overuse headache
ENT: Chronic rhinosinusitis
Psychiatric: Depression, anxiety
Neurological: Intracranial SOL/bleed, benign intracranial hypertension
- Frontal headache, worse lying down, N/V, vision changes
- Optic disc swelling → peripheral vision loss (most common), possible central scotoma
Venous sinus thrombosis: Headache varies (tension-like, daily, migraine-like, thunderclap), ± focal neuro signs, seizures, altered consciousness
Obstructive sleep apnoea: Usually bilateral, improves through the day
Cervicogenic headache: Unilateral/posterior, neck pain, reduced ROM, worse with neck movement/palpation

Management – Medication Overuse Headache

Pathophysiology

Treatment

Gradual dose/frequency reduction of offending drug
Bridging therapy:
- 1st line: Naproxen MR 750 mg OD (2 weeks)
- 2nd line: Prednisolone 50 mg OD x 3 days, then taper (2 weeks total)
Consider prophylaxis if requiring analgesia ≥5 days/month:
- 1st line (tension headache): Amitriptyline/Nortriptyline 10 mg nocte (max 75 mg) for 8 weeks, then review
Psychological therapy referral (address withdrawal anxiety)
Patient education:
- Headaches may worsen first 5–10 days before improving
- Lifestyle modifications: Sleep hygiene, stress management, headache diary
- Medication cessation is key, may require withdrawal phase with temporary headache increase
- Non-pharmacological tension headache management similar to migraine

Headache

Key Notes

Differentials

Primary Headaches
- Migraines (with or without aura)
- Tension-type headache
Vascular Causes
- Temporal (giant cell) arteritis → age >50, scalp tenderness, jaw claudication
- Venous sinus thrombosis → can mimic tension or migraine, ± focal neuro deficits, seizures
Ophthalmic
- Acute angle-closure glaucoma: Severe eye pain, red eye, blurred vision, mid-dilated pupil
Medication-Related
- Medication overuse headache (MOH)
ENT
- Chronic rhinosinusitis → typically facial congestion, purulent nasal discharge
Psychiatric
- Depression, anxiety (somatic manifestations)
Neurological
- Intracranial space-occupying lesion (SOL) or haemorrhage
- Benign intracranial hypertension (idiopathic intracranial hypertension):
  - Frontal headache worsened by lying down
  - Nausea/vomiting, possible visual changes
  - Papilloedema often leads to peripheral vision loss first
Sleep/Respiratory
- Obstructive sleep apnoea: Usually bilateral headache, improves over the day
Cervicogenic Headache
- Unilateral or posterior headache with neck pain, restricted cervical ROM, worsened by neck movement/palpation

Management – Medication Overuse Headache (MOH)

Pathophysiology

Overuse of certain analgesics (>10 days/month for triptans, opioids; >15 days/month for paracetamol, NSAIDs) leads to a rebound headache or chronic daily headache pattern.

Treatment

Gradual Dose/Frequency Reduction
- Discontinue or taper the offending medication.
- Education about possible temporary increase in headache severity (5–10 days) before improvement.
Bridging Therapy
- First Line: Naproxen MR 750 mg OD for 2 weeks
- Second Line: Prednisolone 50 mg OD for 3 days, then taper over 2 weeks total
- Consider prophylactic therapy if analgesic needed ≥5 days/month
Prophylaxis (If Indicated)
- For tension-type headache prophylaxis:
  - Amitriptyline or Nortriptyline 10 mg at night (max ~75 mg) for 8 weeks, then review
- Psychological therapy referral if withdrawal anxiety or significant comorbid stress
Patient Education
- Headache diary: Track triggers, medication use, severity
- Lifestyle modifications: Adequate sleep, stress management, hydration
- Acknowledge initial headache worsening in first 1–2 weeks of medication cessation

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