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From Mediwikis


Adolescent onset, due to pulsation of intracranial arteries.

Can last 1-72 hours


  • Unilateral headache
  • Prodome (patient can predict onset - e.g. cravings, sleep, appetite and mood changes)
  • Aura- "zigzag" or other types
  • Nausea & Vomiting
  • Photophobia

Common Triggers- CHOCOLATE:

  • Cheese
  • Oral contraceptive pill
  • Caffeine(and withdrawal)
  • Alcohol
  • Anxiety
  • Travel
  • Exercise


  • B-blockers
  • Amytriptyline.
  • Find and avoid triggers


  • Rest (resolves with sleep)
  • NSAIDS[1]
  • Triptans.

Tension Headache

Older schoolchildren- "Band" of pressure, worse at the end of the day. Benign, give simple analgesia


  • Bilateral headache - often described as "band" of pressure.
  • No focal neurological symptoms


  • Simple analgesia
  • Stress relief
  • Acupuncture[2]

Subarachnoid Haemorrhage

Bleeding into the sub-arachnoid space caused by head injury (85%), cerebral aneurysm rupture (most cases berry aneurysm) or ateriovenous malformation (AVM).

Risk Factors: Hypertension, Smoking, Alcohol, anticoagulation


  • “Thunderclap headache” - Sudden onset, intense pain to occiput. 
  • Commonly described as like ‘a baseball bat to back of the head’ and ‘first and worst headache’.


  • Seizures
  • Vomitting
  • Reduced GCS.
  • Stiff neck
  • Kernig's sign
  • Cranial Nerve palsy/other focal neurology


  • Emergency referral to neurovascular surgery for intervention e.g. coiling/surgical clipping
  • CT is essential before lumbar puncture (LP).  Doing an LP on a patient with raised intracranial pressure could cause a phenomenon called ‘coning’ – i.e. brainstem compression and damage as a result of herniation through the foramen magnum. 
  • LP should be done ideally >12 hours after bleed as bilirubin in the SAH takes time to breakdown. The xanthochromia in CSF confirms SAH. 
  • Nimodipine is given for vasospasm  
  • BEWARE of Complications: Rebleeding is very common!!!!  

Subdural Haemorrhage

Subdural haemorrhage is bleeding from bridging veins between the dura and arachnoid layers. Most are formed by trauma!

Risk factors: Elderly (as a result of brain atrophy, the bridging veins are more vulnerable) , Alcoholics, Epileptics (more likely to fall), Anticoagulant therapy


  • Fluctuating consciousness
  • Personality Change
  • Sleepiness


  • Raised ICP
  • Seizures
  • Focal neurological symptoms
  • BEWARE: Signs and symptoms can take months to appear!


  • Organise CT/MRI Scan
  • Refer to neurosurgery
  • Patient might need Craniostomy /Craniotomy

Giant Cell Arteritis

Giant cell arteritis (GCA) is a large vessel inflammatory vasculitis, most commonly affecting the temporal artery. Suspect GCA in patients >50 with a new headache – if untreated it can lead to visual loss. GCA is strongly associated with polymyalgia rheumatica (symmetrical pain and stiffness in the shoulder and pelvis).


  • Headache
  • Tender scalp and neck
  • Jaw claudication when chewing
  • Weight loss and malaise
  • Unilateral visual loss


  • ESR (and to a lesser extent CRP)
  • Temporal artery biopsy


  • Initiate high dose corticosteroids as soon as GCA is suspected (before biopsy) –continue for 4 weeks. Corticosteroids are usually continued at a lower dose for the next year.


  1. Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET, Durec T, Klassen TP, Hartling L. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD005220. DOI: 10.1002/14651858.CD005220.pub2.
  2. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD007587. DOI:10.1002/14651858.CD007587.pub2.