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Home | Articles | Neurology | Severe Headache

Severe Headache

Last updated 29th February 2024

Headaches requiring admission are usually severe but not always serious, though important to exclude serious causes in every case.

Consider 5 Serious Causes

  1. SAH – sudden onset of worst ever headache. (See also Subarachnoid Haemorrhage)
  2. Meningitis – suspect if has fever and neck stiffness. Pallor with petechial rash suggests meningococcal septicaemia.
  3. Malignant hypertension – DBP usually > 130 mmHg with bilateral haemorrhages and exudates and/or papilloedema.
  4. Space occupying lesion – suspect brain tumour if headache for a few weeks with drowsiness, focal neurological signs, papilloedema. Suspect cerebral abscess if drowsy with focal neuro signs and fever.
  5. Giant cell arteritis – requires three of the following: age > 50 at onset; new onset localised headache; temporal artery tenderness or decreased pulsation; ESR > 50; positive biopsy.

Red Flags for Secondary Headache 

  1. Worsening headache with fever
  2. Sudden onset headache (onset to maximum severity <5 minutes)
  3. New onset neurological deficit
  4. New onset cognitive dysfunction
  5. Change in personality
  6. Impaired level of consciousness
  7. History of head trauma within 6 weeks
  8. Headache triggered by cough, valsava, sneeze or exertion
  9. Headache that changes with posture
  10. Suspected meningitis
  11. Suspected glaucoma
  12. Suspected temporal arteritis

Primary Headache Severe Enough to Require Admission

  1. Migraine with/without aura
  2. Cluster headache
  3. Tension headache
  4. Thunderclap headache
  5. Medication overuse headache

Migraine With Aura

  1. Typical aura comprises fully reversible visual and/or sensory and/or dysphasia symptoms.
  2. Symptoms may be positive eg flickering lights, zig-zag lines, tingling or negative eg visual loss, numbness. Visual blurring and ‘spots’ are not diagnostic.
  3. Characteristic evolution of symptoms over at least 5 mins and resolution within 60 mins.
  4. Different aura symptoms may occur in succession eg visual to sensory to speech. Leg rarely affected when there are sensory symptoms.
  5. Aura with motor weakness requires referral to exclude other causes
  6. Consider TIA if aura has abrupt onset, is very short or lasts more than one hour.

Migraine Without Aura

  1. Diagnosis likely if:
    • Episodic severe disabling headache.Associated with nausea ‘would you like to eat during a headache?’ and sensitivity to light ‘would light like this bother you during a headache?’.
    • Not daily headache – more likely to be tension.
    • No evidence of medication overuse.
    • Normal neurological examination.
  2. First line treatment is NSAID with paracetamol and metoclopramide given regularly not ‘as required’, in order to break pain cycle. Give IV if nausea oR vomiting.
  3. If ineffective consider sumatriptan 50-100 mg orally or 6 mg subcut, unless patient has CHD or severe hypertension.
  4. If ineffective try another triptan eg almotriptan 12.5 mg orally.
  5. Consider prophylactic therapy if frequent acute attacks eg propranolol 80-240 mg per day, valproate 300-600 mg bd, amitriptyline 25-150 mg per day.

Cluster Headache

  1. This is one of the trigeminal autonomic cephalalgias (TAC).
  2. Features differentiating TAC from migraine are:
    • Severe, strictly unilateral pain located in one or a combination or orbital, supra-orbital or temporal region.
    • Prominent ipsilateral autonomic features eg conjunctival injection, lacrimation, rhinorrhoea or ptosis
    • Each attack starts and ceases abruptly lasting 15 minutes to 3 hours. Attacks often occur at the same time each day and may ‘cluster’ into periods lasting weeks or months separated by periods of headache freedom
    • Patient restless during attack.
  3. First line treatment is breathing 100% oxygen at 10-15 l/min – will abort headache in some patients.
  4. Sumatriptan 6 mg SC relieves headache in 75% patients within 15 minutes.
  5. Prednisolone 30-60 mg daily for 2-5 days may also be effective.
  6. Consider prophylaxis for frequent or prolonged attacks with verapamil 80 mg tds up to 960 mg daily if necessary & if tolerated, or with lithium carbonate.

Tension Type Headache

  1. Common but not generally as disabling as migraine unless it becomes chronic (arbitrarily > 15 days per month for > 3 months) in which case it can be disabling.
  2. Pain typically generalised but may be unilateral. Characteristically pressing or tightening in quality. Photophobia may be present but not nausea and not aggravated by physical activity.
  3. May be stress related, associated with pericranial muscle tenderness, both or neither.
  4. If severe enough to require admission to hospital, first line treatment is paracetamol with NSAID.
  5. Consider prophylaxis with amitriptyline 25-75 mg daily, venlafaxine or gabapentin if tension headache poorly controlled.

Thunderclap Headache

  1. Term used to describe sudden onset of severe headache with time to maximum intensity < 1 minute, that may occur at rest, during exercise or intercourse.
  2. Classic cause is SAH but differential includes intracranial haemorrhage, carotid or vertebral artery dissection, cerebral venous thrombosis and pituitary apoplexy.
  3. Primary thunderclap headache describes a benign, idiopathic and potentially recurrent headache of sudden and severe intensity with a lack of underlying pathology.
  4. All patients with first presentation of sudden severe headache should be referred urgently for assessment which will normally include CT and LP if CT normal.

Medication Overuse Headache (MOH)

  1. An important cause of chronic daily headache.
  2. Patients who use triptans or opiates > 10 days per month or simple analgesics > 15 days per month are at risk.
  3. Headache may have started as migraine or tension and then become MOH.
  4. The only effective treatment is to withdraw the drugs that are being overused – SIGN recommend that this is done gradually for opiates, suddenly for triptans and simple analgesics.
  5. If discontinuation of overuse medication does not resolve headache or result in return to original headache pattern in 2 months, diagnosis should be reconsidered.

Miscellaneous Causes of Headache

  1. Sinus – blocked nose, puffy eyes, nasal discharge.
  2. Dental – eg from root abscess.
  3. Cervical spondylosis – with muscle spasm causing occipital headache (cervicogenic headache)
  4. Sexual headache – but must investigate for subarachnoid if first presentation.
  5. Carbon monoxide poisoning – likely to be drowsy. Clue is poorly ventilated gas or central heating system.

Breaking the Pain Cycle

  1. Regular Paracetamol 1 g qds with Ibuprofen 400mg qds..
  2. If patient vomiting then both drugs can be given IV.
  3. Some patients will require opiate eg oxynorm 5-10 mg every 4-6 hours orally with 2.5-5 mg breakthrough.
  4. Combination of regular oxynorm with IV paracetamol often highly effective as the paracetamol will potentiate the opiate.
  5. Rx metoclopramide 10 mg orally/subcut/IV tds if feeling sick as a result of headache or treatment.


Content Updated by Dr Ondrej Dolezal