This document provides an overview and review of common types of headaches for medical students preparing for an exam. It begins by explaining that headaches are commonly assessed on medical exams and provides background on why this guide was created. It then briefly outlines some of the major headache types that will be covered, including migraines, cluster headaches, trigeminal neuralgia, and increased intracranial pressure. The document is intended as a quick reference for students to review presenting symptoms, typical characteristics, diagnostic criteria and management approaches for common headache conditions.

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Introduction
Have you ever felt that studying about headaches has
actually ended up giving you a headache? Well luckily
you’re not alone. Trying to remember the different
headaches, how they present and how they are treated is
particularly difficult. This guide intends to help you briefly
understand the common cause of headaches.
Headaches are a commonly assessed area on the Applied
Medical Knowledge (AMK) exam and over the past few
years, usually one or two questions are related to
headaches in each exam.
The guide has been prepared especially as a revision tool
for Peninsula Medical School Students who sit the dreaded
AMK exam. In order to successfully tackle the questions in
the AMK, students should have a good all round knowledge
about the patient’s presenting symptoms. Therefore this
guide helps you to produce a differential diagnosis from the
patient’s presenting complaint.
As this is a brief guide it is highly encouraged that you read
about these topics in greater depth, to allow a greater
understanding and use this as a quick reference.
Along with the AMKs this booklet may be used for preparing
for placements, especially at the GP or neurology wards

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Gross Anatomy
Figure 1 - Meninges of the CNS
Epidural Space – Useful in
anaesthetics, also epidural haematoma
may develop.
Dura Matter – Outermost of the 3 layers
of the Meninges, subdural haematoma
occurs when bridging veins damaged!
Subdural Space – artificial space
between the Dura and Arachnoid mater
Arachnoid Matter – Second Meninge
covering the spinal cord
Pia Matter – Delicate innermost of the
FRONTAL LOBE – The front of each
cerebral hemisphere, contains most of
the dopamine-sensitive neurons. Think
of personality change, e.g. Frontal lobe
dementia!
PARIETAL LOBE – Integrates
sensory information from different
modalities. Determines spatial sense
and navigation. Includes somatosensory
cortex.
TEMPORAL LOBE – This is involved
in auditory perception, home to primary
auditory cortex. Includes Wernickes and

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Figure 2 - Brain Lobes
History
QUESTIONS TO ASK
You should ask specifically about the symptoms of the headache -
• Is it Acute/Chronic?
• What was the speed of onset?
• SOCRATES
o S - SITE
o O - ONSET
o C - CHARACTER
o R - RADIATION
o A - ASSOCIATIONS
o T - TIME COURSE
o E - EXACERBATING/RELIEVING FACTORS
o S - SEVERITY (SCALE 1-10)
NOTES

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Subarachnoid
Haemorrhage
WHAT IS THIS?
This is a spontaneous bleed
into the subarachnoid space
and is catastrophic
Incidence – 8/100,000
CLINICAL FEATURES
‘First and Worst’ Headache
Occipital Headache
Vomiting, seizures and coma.
RISK FACTORS
Ruptured saccular aneurysm (>80%)
Atriovenous malformation (15%)
No cause found (<15%)
RFs - Smoking, alcohol misuse,
increased BP, bleeding disorder,
INVESTIGATIONS
CT Scanners detect >90% of
bleeds within first 48 hours
If CT-ve do a lumbar puncture.
CSF would be uniformly bloody
and then xanthochromic after a
MANAGEMENT
Neurosurgical Help required, if confirmed patients require a craniotomy,
followed by clipping or coiling of the aneurysm
Also continue observations on patients – BP, pupils, coma level

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Meningitis
EXTRA NOTES
WHAT IS THIS?
Inflammation of the pia and
arachnoid membranes,
caused by bacteria, viruses,
fungi or other organisms
90% of all cases of meningitis
occur within the first five
CLINICAL FEATURES
Headache, leg pains, cold hands and
feet initially
Later – meningism (neck stiffness and
photophobia) Kernigns sign,
conscious level decreases
CAUSES
Meningococcus,
Pneumococcus, Haemophilus
Influezae, Listeria
Monocytogenes
INVESTIGATIONS
Bloods – FBC UnEs, Blood cultures
Lumbar puncture
Pyogenic CSF – Turbid CSF, with a low
glucose and high protein

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Migraine
MANAGEMENT
Empirical Treatment – Cefotaxime (<55yrs) Cefotaxime and Ampicillin (>55yrs)
Viral Encephalitis - Aciclovir
EXTRA NOTES
WHAT IS THIS?
A debilitating condition
characterised by moderate
to severe headaches and
CLINICAL FEATURES
Visual or other aura, lasting approx 15-30
minutes Aura – visual – chaotic,
cascading, distorting, melting and jumbling
of lines, dots or zigzags or scotoma.
Followed by usually 1hour of
unilateral/throbbing headache
Nausea and vomiting. Other stimuli
RISK FACTORS
CH- cheese
O – oral contraceptives
C - caffeine
OL - alcohol
A - anxiety
DIAGNOSTIC CRITERIA
>5 headaches lasting 4-72
hours with either nausea or
vomiting, with
photo/phonophobia, with
either: unilateral or pulsating
headache, which interferes

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Cluster Headaches
MANAGEMENT
1
st
Line – NSAIDs (aspirin, ketoprofen)
2
nd
Line – Triptans – e.g. Sumatriptan (Useful in first 8 hours)
EXTRA NOTES
WHAT IS THIS?
A type of headache which
may be caused by
superficial temporal artery,
with smooth muscle
hyperactivity to 5HT
CLINICAL FEATURES
Rapid onset of severe pain around one eye,
may become watery and bloodshot, with lid
selling, lacrimation, facial flushing,
rhinorrhoea, miosis and ptosis.
Pain is strictly unilateral and always affects
the same side
Lasts 15-160 mins, occurs once or twice a
day, often nocturnal
DIAGNOSTIC CRITERIA
The diagnosis is made from the history. The
International Headache Society (IHS)
guidelines suggest the following diagnostic
criteria:
At least 5 attacks fulfilling the following:
Severe, or very severe, unilateral orbital,
supraorbital and/or temporal pain lasting 15 to
180 minutes if untreated
Headache accompanied by at least one of:
ipsilateral conjunctival injection and/or
INVESTIGATIONS
History and neurological examination
only are required to make the
diagnosis usually.
As with any primary headache, some
patients may need imaging, and the
red flags of headache indicating the
need to search for a secondary
cause are:
Change in pattern of headache
New headache at age over 50
Onset of seizures
Headache with systemic illness

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Trigeminal Neuralgia
MANAGEMENT
Acute Attack - 100% oxygen for 15 minutes, Followed by sumatriptan Preventatives – 1
st
Line is Verapamil (Calcium channel blocker) or Topiramate (anti-convulsant)
EXTRA NOTES
WHAT IS THIS?
Trigeminal neuralgia can be
described as a chronic,
debilitating condition
resulting in intense and
extreme episodes of pain in
the face. The episodes are
sporadic and sudden and
CAUSES
Compression: blood vessels may press
on the trigeminal nerve as it leaves the
brain stem at its cerebellopontine nerve
root.
Degeneration: some have postulated it to
be part of the ageing process as with
increasing age the brain atrophies leading
to redundant arterial loops which can cause
compression.
DIAGNOSTIC CRITERIA
• Paroxysmal attacks of pain lasting a
second to two minutes and affecting
one or more divisions of trigeminal
nerve (typically maxillary or mandibular
branches)
• Pain has at least one of the following
characteristics: intense, sharp,
superficial, stabbing, precipitated by
trigger areas/factors
• Attacks are similar in individual
patients
INVESTIGATIONS
The diagnosis is clinical and it
can be difficult to make. No
investigations are required
initially unless there is
uncertainty regarding the
diagnosis. Patients who are
referred on for specialist review
will usually have a brain MRI -
this is to document the presence

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Giant Cell Arteritis
MANAGEMENT
Carbmazepine – 100mg/12hr, Lamotrigine, Phenytoin OR Gabapentin
EXTRA NOTES
WHAT IS THIS?
An inflammatory disease of blood
vessels, a form of vasculitis. The
giant cell is the cell involved in the
pathogenesis
The aetiology is unknown, but the
pathogenesis involves a chronic
inflammatory process,
CLINICAL FEATURES
Headache – temporal area of forehead
Temporal artery and scalp tenderness
(e.g. combing hair)
Jaw claudication
RISK FACTORS
Increased prevalence of PMR and GCA
exists in individuals with a European
background, and a decreased incidence
and prevalence is noted in African
Americans.
Most patients with PMR or GCA present
after their sixth decade, and peak
incidence occurs in patients aged 60-80
INVESTIGATIONS
ESR Elevated
Normocytic, normochromic
anaemia and thrombocytopenia
are common
Temporal artery biopsy – Gold

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Increased Intracranial Pressure
MANAGEMENT
For people with visual symptoms, give oral prednisolone 60 mg and arrange an urgent
(same-day) assessment by an ophthalmologist
Start aspirin 75 mg daily unless there are contra-indications, e.g. active peptic ulceration
EXTRA NOTES
WHAT IS THIS?
Raised intracranial pressure
(ICP) can arise as a
consequence of intracranial
mass lesions, disorders of
CSF circulation and more
diffuse intracranial
pathological processes. Its
development may be acute
or chronic. The combination
CLINICAL FEATURES
Headache - worse on coughing or moving head
and associated with altered mental state.
Early changes in mental state include lethargy,
irritability, slow decision making and abnormal
social behaviour. Untreated, can deteriorate to
stupor, coma and death.
Vomiting (in early stages without nausea), which
can progress to projectile with rising ICP.
Pupil changes including irregularity or dilatation in
one eye.

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Encephalitis
CAUSES
Localised mass lesions:
Neoplasms, Abscess
Focal oedema secondary to trauma, infarction,
tumour
Obstructive hydrocephalus,
Diffuse brain oedema or swelling:
INVESTIGATIONS
CT/MRI to determine
underlying lesion.
Check and monitor blood
glucose, renal function,
electrolytes and osmolality.
MANAGEMENT – Depends on cause, anticonvulsants to control ICP, CSF drainage if
required, elevate head of bed, analgesia and sedation. Mannitol (intravascular osmotic
agent)
EXTRA NOTES
WHAT IS THIS?
Encephalitis is inflammation
of the brain parenchyma,
often caused by viral
infections but also by other
pathogenic organisms and
occasionally by other
conditions, e.g. toxins,
CLINICAL FEATURES
Most patients with viral encephalitis
present with the symptoms of meningitis
(fever, headache, neck stiffness, vomiting)
followed by altered consciousness,
convulsions, and sometimes focal
neurological signs, signs of raised
intracranial pressure, or psychiatric
RISK FACTORS
HIV Infection, Viral (herpes simplex, EBV,
mumps, measles and enteroviruses)
Bacterial – TB, mycoplasma, listeria, lyme
INVESTIGATIONS
CSF
FBC and Blood Film
CT, MRI Scan

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Other Headaches to Consider
MANAGEMENT
Urgent hospital admission, prompt treatment with IV acyclovir
IV fluids
EXTRA NOTES
ACUTE GLAUCOMA - An opthamology condition, usually acute closed angle
glaucoma. Symptoms with this include – red eye, sees haloes, fixed and dilated
pupil! Decreased acuity. Diagnosis is made on history and examination.
Refer immediately – Intravenous Acetazolamide. Other topical agents given e.g.
ACUTE SINUSITIS – This is an inflammation of membranous lining of one or
more of the sinuses. This is defined as a bacterial or viral infection of the sinuses
lasting fewer than four weeks and resolving completely. It is most commonly
caused by Streptococcus pneumonia, Haemophilus Influenzae and Moraxella
Catarrhalis. Acute sinusitis is diagnosed if there is facial discomfort, nasal
obstruction and decreased or absent sense of smell. Management –

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Test Yourself
TENSION HEADACHE - Typically described as pressure or tightness, like a vice
or tight band around the head. There is often a relationship to the neck, with pain
into or from the neck. These headaches can be disabling for a few hours but lacks
the specific features and associated symptoms of migraine.
Management – Ibuprofen, Diclofenac, Naproxen, Paracetamol (if intolerant to
MEDICATION OVERUSE HEADACHE - Medication-overuse headache is
caused by taking painkillers or triptan drugs too often for tension-type headaches or
migraine attacks. It is a common cause of headaches that occur daily, or on most
days. Diagnosed by taking and accurate history. Treated by withdrawing the
NOTES
QUESTION 1) A 50 year old woman attends the AnE department complaining of an acute
headache, she describes this as her first and worst headache. She has also been vomiting
for the past couple of hours. CT Scan reveals a fresh bleed in the anterior circulation.
What is the most likely diagnosis?
 A – Migraine
 B – Extradural Haemorrhage
 C – Meningioma
 D – Subarachnoid Haemorrhage

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Test Yourself
QUESTION 2) You review a 64 year old lady at a GP practice. She complains of pain
over her right forehead, which is worse when she combs her hair. She also has some pain
on chewing.
What would be your initial management?
 A – Advise some simple analgesia
 B – Arrange an urgent CT scan of the brain
 C – Commence high dose prednisolone (steroids)
 D – Perform a lumbar puncture
QUESTION 3) A 46 year old male bank manager comes to you complaining of a right sided
throbbing headache, with photophobia. He has had these symptoms at least once a week for the past
month. What is the most likely diagnosis?
 A – Analgesic overuse headache
 B – Meningitis
 C – Migraine
 D – Increased intracranial pressure headache
QUESTION 4) A 2 year old boy attends the ED with his mother, who says her son has been irritable
all morning, crying and developed a rash all over. You examine the child who is very irritable and has
a temperature. You notice the rash is non-blanching and he does not like you assessing his neck.
What is the most likely diagnosis?
 A –Cluster headache
 B – Subdural Haemorrhage
 C – A fall resulting in an extradural haemorrhage
 D – Measles

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Extra Resources
The following sources may be used to gather more information on the
content discussed within this booklet.
1 – Patient.co.uk – (The section on headaches.) http://www.patient.co.uk
2 – GP Notebook.com – (Look up each condition separately.)
http://www.gpnotebook.com
QUESTION 5) A 57 year old lady with a longstanding history of epilepsy has been brought in by her
daughter, she is suffering with fluctuation in her conscious level and seems to have some weakness in
the right hand side of her body. This has come on suddenly over the past few hours. What is the most
likely diagnosis?
 A – Extradural Haemorrhage
 B – Subdural Haemorrhage
 C – Cluster headache
 D – Medication overuse headache
ANSWERS – 1-D 2-C 3-C 4-E 5-B

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3 – Tortora GJ, Derrickson BH. Principles of Anatomy and Physiology.
11
th
ed. John Wiley and Sons; 2005
4 – Longmore M, Wilkinson I, Turmezei T, Kay Cheung C. Oxford
Handbook of Clinical Medicine. 7
th
ed. Oxford: Oxford University Press;
2007
5 – International Headache Society - http://www.ihs-headache.org/
Please Note:
Images are sourced from Wikipedia.com which allows permission
specifically granted for this learning resource.
Special Thanks to –
All of the participants including medical students, Neurology Consultants
and the SSU providers for their input and support in producing this
booklet.