Recurrent moderate-severe headache, unilateral, throbbing, with photophobia/phonophobia ± aura.
Risk factors
- • Female, family history
- • Stress, sleep change, OCP, menstruation
History taking
- • 4–72 h, unilateral, pulsating, aggravated by activity
- • Nausea, photo/phonophobia, aura
Examination
- • General: vitals, pallor, icterus, oedema, lymphadenopathy
- • Focused system examination
- • Look for red-flag findings
Red flags
- • Thunderclap onset, fever, focal neurology, age >50 first headache → image
Differential diagnosis
- • See differentials section per chief complaint
Recommended investigations
- • Clinical; MRI only if red flags
Diagnosis
- • Clinical diagnosis supported by targeted investigations
Initial treatment / management
- • Treat underlying cause
- • Symptomatic relief
- • Patient education
Drug therapy
- • Acute: ibuprofen 400–600 mg or sumatriptan 50–100 mg PO
- • Add metoclopramide 10 mg for nausea
- • Prevent (≥4/month): propranolol 40–160 mg/day, topiramate 25–100 mg, amitriptyline 10–50 mg ON
Lifestyle advice
- • Headache diary, sleep hygiene
- • Trigger avoidance, hydration
- • Limit acute meds to <10 days/month
Follow-up advice
- • Review in 2–4 weeks or earlier if worsening
- • Monitor response to therapy and adverse effects
Patient counselling
- • Explain diagnosis and natural course in lay terms
- • Red-flag symptoms warranting urgent return
- • Adherence to medications and follow-up
Referral criteria
- • Refer if diagnostic uncertainty, complications, or failure of first-line therapy
Clinical pearls
- • Medication-overuse headache: stop triptans/opioids/caffeine
References
- • Harrison's Principles of Internal Medicine, 21e
- • NICE / WHO guidelines (current edition)
Educational outpatient guide — verify against local guidelines before clinical use.
