Step 2 CK · Neurology

Headache & Facial Pain

Name: Headache & Facial Pain
Creator: Veli Bakalov, MD

Abort and prevent the primary headaches, and never miss the dangerous secondary ones

Neurology·Seizures & Headache·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

Study materialsNo account needed

Card deckActive-recall cards · quick checks · quiz

High-yield

Screen every headache with SNOOP (systemic signs, neurologic deficits, sudden onset, older age >50, pattern change/positional/papilledema); any red flag → imaging or urgent workup before symptomatic treatment.
Migraine = unilateral, pulsating, 4–72 h, nausea, photophobia and phonophobia, worse with activity (POUND); abort mild attacks with NSAIDs and moderate-severe ones with a triptan ± metoclopramide.
Triptans and ergots are vasoconstrictors, contraindicated in coronary artery disease and uncontrolled hypertension; avoid estrogen contraceptives in migraine with aura.
Migraine prevention for ≥4 attacks per month or disabling attacks: propranolol or metoprolol, topiramate, amitriptyline, valproate, or CGRP-targeting therapy (antibodies such as erenumab, or gepants; first-line per AHS 2024), chosen by comorbidity.
Tension-type = bilateral band-like pressure without nausea → NSAIDs or acetaminophen, amitriptyline if frequent; analgesic or triptan use ≥10–15 days/month causes medication-overuse headache → withdraw the agent.
Cluster = excruciating unilateral periorbital pain for 15–180 min with ipsilateral lacrimation, rhinorrhea, ptosis and miosis in a restless man → 100% oxygen plus subcutaneous sumatriptan; verapamil prevents.
Thunderclap headache → non-contrast CT (normal within 6 hours of onset essentially excludes SAH); if negative after 6 hours with persistent suspicion → LP for xanthochromia to exclude subarachnoid hemorrhage.
Giant cell arteritis (>50, jaw claudication, scalp tenderness, high ESR/CRP) → high-dose steroids immediately, biopsy afterward, to prevent blindness from anterior ischemic optic neuropathy.
IIH (obese young woman, papilledema, pulsatile tinnitus, high opening pressure, normal imaging) → weight loss plus acetazolamide; trigeminal neuralgia → carbamazepine (think MS if young or bilateral).

Approach: primary or secondary?

Most headaches are primary (migraine, tension-type, cluster) and benign. The task is to catch the dangerous secondary headaches, screening every patient with the SNOOP red flags:

Systemic symptoms: fever, weight loss, cancer, immunosuppression
Neurologic deficits
Onset sudden (thunderclap)
Older age at onset (over 50)
Pattern change, Positional headache, or Papilledema

Any positive flag prompts imaging or urgent workup before symptomatic treatment; a thunderclap, first-or-worst, or progressive headache with neurologic signs demands imaging first.

Thunderclap onsetNon-contrast CT, then LP.
Age over 50 plus jaw claudicationESR/CRP, steroids, then biopsy.
Papilledema in an obese young womanImaging, then LP opening pressure.
Focal deficit or progressive courseMRI brain.

Red-flag triage

The primary headaches

Migraine vs tension-type vs cluster

Feature	Migraine	Tension-type	Cluster
Location and quality	Unilateral, pulsating, moderate to severe	Bilateral, band-like, pressing, mild to moderate	Unilateral periorbital, excruciating
Duration	4–72 hours	30 minutes to days	15–180 minutes, recurring in clusters
Associated features	Nausea, photophobia, phonophobia, ± aura; worse with activity	No nausea; not worsened by activity	Ipsilateral lacrimation, rhinorrhea, conjunctival injection, ptosis and miosis
Behavior	Lies still in a dark room	Carries on	Paces, restless, agitated
Sex	More common in women	Common in both	More common in men
Acute treatment	NSAIDs; triptan ± antiemetic	NSAIDs or acetaminophen	100% oxygen plus subcutaneous sumatriptan
Prevention	β-blocker, topiramate, amitriptyline, valproate, CGRP antibody	Amitriptyline for frequent episodes	Verapamil

Migraine fits the mnemonic POUND: Pulsatile, One-day duration (4–72 hours), Unilateral, Nausea, Disabling. A visual aura of scotoma or scintillating zigzag lines may precede the pain.

Cluster headache typically strikes at the same time each night during a cluster period. Oxygen and subcutaneous sumatriptan abort attacks; verapamil prevents them.

Managing migraine

Acute attacks. Treat mild attacks with NSAIDs or acetaminophen, and moderate-to-severe attacks with a triptan such as sumatriptan taken at onset, often with an antiemetic like metoclopramide.

Triptans and ergots cause vasoconstriction and are contraindicated in coronary artery disease and uncontrolled hypertension. Estrogen-containing contraceptives are avoided in migraine with aura because of ischemic stroke risk.

Prevention is indicated for ≥4 attacks per month or for disabling attacks, taken daily and chosen by comorbidity:

Choosing migraine prophylaxis

Agent	Favored when	Avoid or caution
Propranolol or metoprolol	Hypertension, anxiety	Asthma (propranolol), bradycardia
Topiramate	Obesity	Kidney stones, pregnancy; cognitive slowing
Amitriptyline	Insomnia, coexisting tension-type headache	Elderly, weight gain, anticholinergic effects
Valproate	Coexisting bipolar disorder	Pregnancy, liver disease
CGRP-targeting therapies (erenumab and other antibodies; gepants such as atogepant)	A first-line option per AHS 2024; cost and access often set the order	Newer and costly

Medication-overuse (rebound) headache results from frequent use of analgesics, triptans, or combination agents, typically on 10–15 or more days per month. Withdraw the overused agent and optimize preventive therapy.

Dangerous secondary headaches

Thunderclap headache (the worst of one's life, maximal within seconds) is subarachnoid hemorrhage until proven otherwise; aneurysmal SAH is the classic cause. Get a non-contrast head CT; a normal CT within 6 hours of onset in a neurologically intact patient essentially excludes SAH. If CT is done later and is negative but suspicion remains, perform an LP looking for xanthochromia (or CT angiography).

Giant cell (temporal) arteritis causes a new headache after age 50 with scalp tenderness, jaw claudication, visual symptoms, and often polymyalgia rheumatica; ESR and CRP are elevated. Start high-dose corticosteroids immediately, then confirm with temporal artery biopsy, which stays positive for days after steroids begin.

Never wait for the biopsy in giant cell arteritis: irreversible monocular blindness from anterior ischemic optic neuropathy can come first.

Idiopathic intracranial hypertension (pseudotumor cerebri) affects obese women of childbearing age: headache, papilledema, transient visual obscurations, pulsatile tinnitus, and sometimes CN VI palsy. Imaging is normal (MR venography excludes venous sinus thrombosis), and LP shows a high opening pressure. Associations include vitamin A excess, tetracyclines, and isotretinoin. Treat with weight loss and acetazolamide (which reduces CSF production); a shunt or optic nerve sheath fenestration is needed if vision is threatened.

Mass lesions and raised ICP cause a progressive headache that is worse in the morning, with Valsalva, or when lying down, accompanied by vomiting, focal deficits, or papilledema. Image with MRI, and avoid LP if a mass with edema is suspected because of herniation risk.

Trigeminal neuralgia

Electric-shock facial pain. Trigeminal neuralgia causes paroxysmal, electric, unilateral pain in the trigeminal V2 or V3 distribution, triggered by light touch, chewing, or cold air. First-line therapy is carbamazepine; microvascular decompression of a vessel compressing the nerve root helps refractory cases.

Trigeminal neuralgia in a young patient, or bilateral symptoms, suggests multiple sclerosis and warrants MRI.