📋 Key Information Summary
- Headache affects approximately 15% of Australians at any given time and is the most common neurological reason for GP consultation.
- Use the SNOOP mnemonic (Systemic symptoms, Neurological signs, Onset sudden, Older age, Pattern change) to screen for secondary (dangerous) headaches.
- Primary headaches — migraine, tension-type headache (TTH), and cluster headache — account for >90% of presentations; a structured history is the single most important diagnostic tool.
- Migraine: unilateral, pulsating, 4–72 h, with nausea/vomiting or photo-/phonophobia; ± aura (visual, sensory, or speech disturbance lasting 5–60 min).
- Tension-type headache: bilateral, pressing/tightening (non-pulsating), mild–moderate, no nausea; most common primary headache worldwide.
- Cluster headache: strictly unilateral orbital/superotemporal pain with autonomic features (lacrimation, rhinorrhoea, ptosis, miosis), 15–180 min per attack, occurring in bouts.
- Thunderclap headache (peak intensity within 1 minute) is subarachnoid haemorrhage until proven otherwise — urgent CT brain ± LP required.
- Acute migraine: first-line is oral NSAID or paracetamol; triptans (sumatriptan, eletriptan) are first-line for moderate–severe attacks or when simple analgesia fails.
- Preventive migraine therapy should be considered when attacks occur ≥4 days/month or cause significant disability; options include propranolol, amitriptyline, topiramate, and CGRP monoclonal antibodies (PBS authority-required).
- Headache in pregnancy requires a low threshold for neuroimaging — paracetamol is first-line; aspirin and triptans require specialist guidance; avoid ergots entirely.
- New-onset headache in patients aged ≥50 years must prompt evaluation for giant cell arteritis (temporal artery biopsy + ESR/CRP) and space-occupying lesions.
- Aboriginal and Torres Strait Islander peoples experience headache at higher rates but face barriers to specialist access; culturally safe care and remote telehealth pathways are essential.
Introduction & Australian Epidemiology
Headache is one of the most prevalent human conditions and the most frequent neurological symptom presenting to Australian general practice. The International Classification of Headache Disorders, 3rd edition (ICHD-3) divides headaches into primary (the headache itself is the disorder) and secondary (the headache is a symptom of an underlying condition). Accurate classification depends on a meticulous history, targeted examination, and judicious investigation.
In Australia, headache accounts for an estimated 4–5% of all GP encounters annually, and migraine alone affects approximately 4.9 million Australians (AIHW, 2023). The economic burden exceeds billion per year when direct healthcare costs, lost productivity, and carer burden are included. Tension-type headache is the most common primary headache globally, while migraine ranks as the second most disabling neurological condition measured by years lived with disability (GBD 2019 Neurology Collaborators).
Cluster headache, though less prevalent (0.1–0.4% lifetime prevalence), causes some of the most severe pain known in medicine. Secondary headaches — including subarachnoid haemorrhage, meningitis, space-occupying lesions, giant cell arteritis, and idiopathic intracranial hypertension — must be identified promptly, as delayed diagnosis carries significant morbidity and mortality.
Diagnostic imperative: Approximately 1–3% of patients presenting to primary care with headache will harbour a serious secondary cause. A systematic approach to red-flag identification is essential to avoid both missed diagnoses and unnecessary investigation.
Headache Diagnostic Model
The diagnostic approach to headache proceeds in three steps: (1) identify red flags for secondary headache; (2) apply ICHD-3 criteria to classify the primary headache phenotype; and (3) recognise comorbidities and medication-overuse headache (MOH).
Step 1 — Red-Flag Screening (SNOOP Mnemonic)
S
Systemic symptoms or signs
Fever, weight loss, HIV, malignancy, pregnancy
N
Neurological signs or symptoms
Focal deficit, papilloedema, confusion, seizures
O₁
Onset — sudden (thunderclap)
Peak intensity < 1 minute — SAH until proven otherwise
O₂
Onset — older age (> 50 years)
Giant cell arteritis, mass lesion, idiopathic intracranial hypertension
P
Pattern change
Progressive worsening, positional, post-traumatic, precipitated by Valsalva
Step 2 — Detailed History for Primary Headache Classification
A structured headache history should cover:
- Location: unilateral vs bilateral; orbital/periorbital vs diffuse
- Quality: pulsating, pressing/tightening, stabbing, burning
- Intensity: mild / moderate / severe (numeric rating scale 0–10)
- Duration: minutes, hours, or days per attack
- Frequency: attacks per month; episodic vs chronic
- Associated features: nausea, vomiting, photo-/phonophobia, aura, autonomic features, restlessness
- Triggers: stress, sleep disturbance, alcohol, menstrual cycle, weather
- Medication use: analgesic frequency (≥15 days/month = possible MOH)
- Family history: migraine has strong genetic component (60–80% heritability)
Step 3 — Physical Examination
A focused neurological examination should be performed in all new-onset headaches. Assess:
- Vital signs (hypertension, fever, tachycardia)
- Fundoscopy — papilloedema (IIH, mass lesion), subhyaloid haemorrhage (SAH)
- Pupillary reflexes — relative afferent pupillary defect (optic neuritis)
- Cranial nerve examination — CN III, IV, VI palsy (pituitary apoplexy, aneurysm)
- Motor, sensory, coordination, and gait assessment
- Temporal artery palpation — tenderness, thickening, reduced pulse (GCA)
- Neck range of motion and meningeal signs if indicated
Medication-Overuse Headache (MOH)
MOH is diagnosed when headache occurs on ≥15 days/month in a patient with a pre-existing headache disorder and regular overuse of acute medications for >3 months. Overuse thresholds: simple analgesics ≥15 days/month; triptans, opioids, or combination analgesics ≥10 days/month. Management involves withdrawal of the overused agent, bridge therapy (e.g., naproxen, prednisolone), and initiation of preventive treatment.
Migraine vs Tension vs Cluster Headache Comparison
| Feature | Migraine | Tension-Type Headache | Cluster Headache |
|---|---|---|---|
| Prevalence (Australia) | ~12–15% (♀ 3:1) | ~38–46% | 0.1–0.4% |
| Location | Unilateral (60%); can be bilateral | Bilateral, band-like | Strictly unilateral, orbital/superotemporal |
| Quality | Pulsating / throbbing | Pressing / tightening (non-pulsating) | Stabbing / boring / excruciating |
| Severity | Moderate to severe | Mild to moderate | Very severe (10/10); "suicide headache" |
| Duration | 4–72 h | 30 min – 7 days | 15–180 min |
| Frequency | 1–4/month (episodic); ≥15 d/month (chronic) | <1 d/month to daily (chronic) | Every other day – 8/day during bouts |
| Autonomic features | None (± lacrimation in severe attacks) | None | Ipsilateral lacrimation, conjunctival injection, rhinorrhoea, ptosis, miosis, eyelid oedema |
| Nausea / vomiting | Yes (80%) | No | Rare |
| Photo-/phonophobia | Yes (both) | One or neither | Rare |
| Restlessness | Prefers to lie still | No restlessness | Pacing, rocking, agitation |
| Aura | 25–30% (visual most common) | None | None |
| Circadian pattern | Morning predominance | Afternoon / evening | Nocturnal (1–2 AM); clock-like regularity |
| Alcohol trigger | Occasional | Not typical | During bouts (always) |
| Sex predilection | Female (3:1) | Slight female predominance | Male (3:1) |
Acute Treatment Comparison
Sumatriptan
Imigran® · Serotonin 5-HT₁B/₁D agonist
Adult dose (migraine)
50–100 mg PO stat; or 6 mg SC stat; or 10–20 mg intranasal
Adult dose (cluster)
6 mg SC stat (first-line); repeat in 1 h if needed (max 12 mg/day)
Frequency
PRN; max 300 mg/day (PO) or 12 mg/day (SC)
Renal adjustment
Mild–moderate impairment: use with caution; severe: avoid
Hepatic adjustment
Reduced clearance — use lower doses
PBS status
✔ PBS General Benefit
Eletriptan
Relpax® · Serotonin 5-HT₁B/₁D agonist
Adult dose
40 mg PO stat; may repeat in 2 h (max 80 mg/day)
Paediatric dose
Not recommended < 18 years
Renal adjustment
No adjustment required
PBS status
Authority Required
Naproxen sodium
Naprosyn® · NSAID
Adult dose
500–1000 mg PO stat with food
Renal adjustment
eGFR < 30: avoid
PBS status
✔ PBS General Benefit
Preventive Treatment Overview
Propranolol
Inderal® · β-blocker
Adult dose
40 mg PO BD, titrate to 80–160 mg/day in divided doses
Renal adjustment
No adjustment
PBS status
✔ PBS General Benefit
Amitriptyline
Endep® · TCA
Adult dose
10 mg PO nocte, titrate by 10 mg every 2 weeks to 25–75 mg nocte
Renal adjustment
No specific adjustment; caution in severe impairment
PBS status
✔ PBS General Benefit
Topiramate
Topamax® · Anticonvulsant
Adult dose
25 mg PO nocte, titrate weekly by 25 mg to 50–100 mg BD
Renal adjustment
eGFR < 30: use with caution; avoid if on dialysis
PBS status
Authority Required
Erenumab
Aimovig® · Anti-CGRP mAb
Adult dose
70 mg SC once monthly (may increase to 140 mg monthly)
Renal adjustment
No adjustment required
PBS status
Authority Required (Specialist)
Thunderclap Headache & Red Flags
Thunderclap headache — peak intensity within 1 minute of onset — is subarachnoid haemorrhage (SAH) until proven otherwise. This is a medical emergency requiring immediate assessment, non-contrast CT head (sensitivity ~98% within 6 h), and lumbar puncture if CT is negative or presentation is >6 h from onset.
Causes of Thunderclap Headache
| Aetiology | Key Features | Initial Investigation |
|---|---|---|
| Subarachnoid haemorrhage | Worst headache ever, meningism, ± LOC, vomiting | Non-contrast CT → LP (xanthochromia) → CT angiography |
| Cerebral venous sinus thrombosis | Progressive or thunderclap; may be subacute; risk in pregnancy, COCP, prothrombotic states | CT venography or MR venography |
| Reversible cerebral vasoconstriction syndrome | Recurrent thunderclap headaches over days; often triggered by exertion, vasoactive drugs, postpartum | CT angiography (segmental vasoconstriction) |
| Arterial dissection (carotid/vertebral) | Unilateral headache/neck pain, Horner syndrome, focal ischaemic signs | CT angiography or MRA neck |
| Meningitis / encephalitis | Fever, meningism, altered consciousness, rash (meningococcal) | Blood cultures → LP → CT head if focal signs |
| Pituitary apoplexy | Sudden headache, visual field defects, ophthalmoplegia, endocrine collapse | Urgent MRI pituitary, cortisol, TFTs, FBC |
| Spontaneous intracranial hypotension | Orthostatic headache (worse upright, better supine); history of LP or spinal procedure | MRI brain with gadolinium (pachymeningeal enhancement) |
| Acute hypertensive crisis | Severe headache with systolic BP > 180 mmHg; target organ damage | BP measurement, fundoscopy, CT head, troponin, UEC |
Other Red-Flag Features Requiring Urgent Investigation
Monitor
New headache after age 50
Consider GCA, mass lesion, idiopathic intracranial hypertension
Setting: GP urgent referral within 1 week
Urgent
Progressive headache with papilloedema or focal neurology
Space-occupying lesion, cerebral venous thrombosis, IIH
Setting: ED or neurology within 24–48 h
Emergency
Thunderclap, fever + meningism, post-traumatic, immunocompromised
SAH, meningitis, epidural/subdural haematoma, cerebral abscess
Setting: ED immediate
Giant Cell Arteritis (GCA) — Specific Red Flag in the Elderly
Giant cell arteritis must be considered in any patient >50 years with new-onset headache, jaw claudication, scalp tenderness, visual disturbances, or ESR >50 mm/h. Untreated GCA risks permanent blindness (anterior ischaemic optic neuropathy). Start prednisolone 1 mg/kg/day (max 60 mg) immediately if clinical suspicion is high — do not wait for temporal artery biopsy. Refer urgently to rheumatology.
Headache in Pregnancy & the Elderly
Headache in Pregnancy
Headache during pregnancy requires careful evaluation because the differential diagnosis broadens significantly. Pre-existing migraine often improves (especially in the 2nd and 3rd trimesters) due to stable oestrogen levels, but new-onset or worsening headache demands a low threshold for investigation.
Pre-eclampsia/eclampsia: New headache after 20 weeks gestation with hypertension (≥140/90 mmHg) and proteinuria is pre-eclampsia until proven otherwise. Severe headache with visual disturbances, RUQ pain, or hyperreflexia warrants immediate obstetric and medical assessment. Magnesium sulphate is first-line for seizure prophylaxis (eclampsia). Definitive treatment is delivery.
| Treatment | Safety in Pregnancy | Notes |
|---|---|---|
| Paracetamol | Safe in all trimesters | First-line acute treatment; max 4 g/day |
| Ibuprofen / Naproxen | Avoid after 30 weeks (ductus arteriosus closure) | May be used in 2nd trimester with caution |
| Aspirin (low-dose) | Safe at 75–150 mg/day for pre-eclampsia prophylaxis | Not for acute headache treatment |
| Sumatriptan | Not teratogenic in registry data but not formally PBS-approved in pregnancy | May be considered under specialist advice for severe, refractory migraine |
| Ergotamine / dihydroergotamine | Contraindicated — uterotonic | Absolutely contraindicated in pregnancy and breastfeeding |
| Propranolol | Generally safe; monitor neonate for bradycardia | Preferred migraine preventive in pregnancy |
| Amitriptyline | Use if benefits outweigh risks | Monitor neonate for withdrawal effects |
| Topiramate | Avoid — teratogenic (cleft palate) | Contraindicated; switch to propranolol or amitriptyline |
| Sodium valproate | Contraindicated — neural tube defects | Absolutely contraindicated in pregnancy of childbearing potential |
Headache in the Elderly (≥65 Years)
New-onset headache in older adults is more likely to be secondary compared to younger patients. The most important causes to exclude are:
- Giant cell arteritis: temporal headache, jaw claudication, visual loss, ESR >50 mm/h — treat empirically with prednisolone and refer for temporal artery biopsy
- Space-occupying lesion: progressive headache worse in morning, worse with Valsalva, with focal neurology or cognitive change — CT/MRI with contrast
- Idiopathic intracranial hypertension: rare in elderly but possible with obesity and tetracycline use
- Medication-related: nitrates, PDE5 inhibitors, calcium-channel blockers, NSAIDs
- Occipital neuralgia and cervicogenic headache: increasingly common with cervical spondylosis
Diagnostic caution: Migraine with aura can present for the first time in older adults and must be differentiated from transient ischaemic attack (TIA). Migraine aura typically evolves over 5–60 minutes (positive symptoms such as fortification spectra), while TIA is sudden onset (negative symptoms such as loss of function). Consider neurovascular workup when uncertain.
Acute and preventive treatment in the elderly requires dose adjustment for renal and hepatic function, increased sensitivity to CNS side effects, and awareness of polypharmacy. Start low, go slow. NSAIDs should be used with caution due to GI bleeding risk. Propranolol is relatively contraindicated in severe COPD and heart failure; candesartan or amitriptyline may be preferred alternatives.
Investigations
Primary headaches are diagnosed clinically and do not require neuroimaging. Investigations are indicated when red flags are present or a secondary cause is suspected.
Essential
Non-contrast CT head
First-line for suspected SAH (sensitivity ~98% within 6 h), mass lesion, or acute head trauma. Available at all Australian public hospitals with ED. MBS item 56001.
Essential
Lumbar puncture
If CT negative but SAH suspected (>6 h onset); meningitis/encephalitis; idiopathic intracranial hypertension. Measure opening pressure, cell count, glucose, protein, xanthochromia (spectrophotometry). MBS item 18360.
Available
MRI brain with contrast
Superior for posterior fossa lesions, venous sinus thrombosis (MRV), demyelination, and intracranial hypotension. MBS item 63001 (requires specialist referral).
Available
CT angiography / CT venography
SAH source (aneurysm), arterial dissection, cerebral venous sinus thrombosis, RCVS. Available at most metropolitan hospitals.
Available
ESR / CRP
Elevated in GCA, infection, malignancy. ESR >50 mm/h in suspected GCA should prompt urgent treatment and temporal artery biopsy referral.
Referral
Temporal artery biopsy
Definitive diagnosis of GCA. Ideally within 2 weeks of starting corticosteroids. Refer to vascular surgery or rheumatology.
Available
FBC, UEC, LFTs, coagulation studies
Baseline tests for patients with secondary headache, anticoagulant use, or pre-procedural assessment.
Specialist
Formal visual field testing (perimetry)
Suspected IIH or pituitary lesion — refer to ophthalmology. MBS item 10817.
Acute Management of Primary Headache
Migraine — Acute Treatment Ladder
1
Mild–Moderate Attack
Paracetamol 1 g PO stat (max 4 g/day) or Aspirin 900–1000 mg PO stat or Ibuprofen 400 mg PO stat. Add metoclopramide 10 mg PO if nausea prominent.
2
Moderate–Severe or Simple Analgesia Fails
Sumatriptan 50–100 mg PO stat (or 6 mg SC for rapid effect) or Eletriptan 40 mg PO stat. Combine with NSAID (e.g., naproxen 500 mg).
3
Vomiting / Unable to Take Oral
Sumatriptan 6 mg SC or Sumatriptan 20 mg intranasal or Prochlorperazine 12.5 mg IM or Metoclopramide 10 mg IV/IM.
4
Refractory / Status Migrainosus (>72 h)
ED presentation: IV metoclopramide 10–20 mg + dexamethasone 8 mg IV or IV prochlorperazine 12.5 mg. Consider admission for IV hydration and anti-emetics.
Triptan best practice: Triptans are most effective when taken early in the attack (within 1 hour of onset). Use no more than 2 days/week to avoid medication-overuse headache. Contraindicated in cardiovascular disease, uncontrolled hypertension, and hemiplegic migraine.
Tension-Type Headache — Acute Treatment
- First-line: Paracetamol 1 g PO stat or aspirin 600–900 mg PO stat or ibuprofen 400 mg PO stat
- Combination analgesics (e.g., paracetamol/codeine) should be limited to ≤2 days/week due to MOH risk
- Triptans are not indicated for TTH
- Non-pharmacological strategies: stress management, physiotherapy, regular sleep, exercise, cognitive behavioural therapy
Cluster Headache — Acute Treatment
Sumatriptan SC
Imigran Injection® · 5-HT₁B/₁D agonist
Adult dose
6 mg SC stat; repeat in 1 h if needed (max 12 mg/day)
Onset of action
5–15 min (fastest abortive agent)
PBS status
✔ PBS General Benefit
High-flow oxygen
100% O₂ via non-rebreather mask
Adult dose
12–15 L/min via non-rebreather for 15–20 min
Notes
Effective in ~70% of attacks; useful as adjunct or when triptans contraindicated. Prescribe home oxygen for cluster patients.
Cluster Headache — Transitional and Preventive Therapy
- Transitional (bridge): Prednisolone 1 mg/kg/day (max 60 mg) for 5 days then taper over 2–3 weeks; or greater occipital nerve block (bupivacaine + corticosteroid)
- Episodic cluster prophylaxis: Verapamil 80 mg TDS, titrate to 240–480 mg/day with ECG monitoring (risk of QT prolongation/heart block at higher doses)
- Refractory cluster: Lithium 300 mg BD–TDS (monitor levels), galcanezumab 300 mg SC monthly (PBS authority-required for specialist-initiated chronic cluster)
- TACs (SUNCT/SUNA): Lamotrigine 25–200 mg/day is first-line
Migraine Preventive Therapy
Preventive therapy should be considered when migraine occurs on ≥4 days/month, causes significant disability despite acute treatment, or when acute medications are contraindicated or overused. A minimum 2–3 month trial at adequate dose is required before judging efficacy.
| Drug | Starting Dose | Target Dose | Key Side Effects | PBS Status |
|---|---|---|---|---|
| Propranolol | 20 mg BD | 40–80 mg BD | Fatigue, bradycardia, bronchospasm | General Benefit |
| Candesartan | 4 mg daily | 16–32 mg daily | Hyperkalaemia, hypotension, cough | General Benefit |
| Amitriptyline | 10 mg nocte | 25–75 mg nocte | Sedation, dry mouth, weight gain, cardiac conduction | General Benefit |
| Topiramate | 25 mg nocte | 50–100 mg BD | Cognitive slowing, paraesthesia, renal stones, weight loss | Authority Required |
| Erenumab | 70 mg SC monthly | 70–140 mg SC monthly | Injection-site reactions, constipation | Authority Required (Specialist) |
| Fremanezumab | 225 mg SC monthly or 675 mg quarterly | Same as starting | Injection-site reactions | Authority Required (Specialist) |
| Galcanezumab | 120 mg SC monthly (after 240 mg loading) | Same as starting | Injection-site reactions | Authority Required (Specialist) |
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are PBS-listed (authority-required) for chronic migraine (≥15 headache days/month, ≥8 migraine days) when ≥3 preventive drug classes have failed. These are initiated by neurologists or headache specialists.
Special Populations
Pregnancy & Breastfeeding
Acute: Paracetamol first-line; avoid NSAIDs after 30 weeks; sumatriptan may be considered under specialist guidance
Preventive: Propranolol (preferred); amitriptyline acceptable; avoid topiramate and valproate
Red flag: New headache after 20 weeks → rule out pre-eclampsia (BP, urinalysis, bloods)
Breastfeeding: Paracetamol, ibuprofen, sumatriptan compatible; avoid ergotamines
Paediatrics
Prevalence: Migraine affects ~10% of children by age 12; TTH becomes more common in adolescence
Acute: Paracetamol 15 mg/kg PO stat (max 1 g); ibuprofen 10 mg/kg PO stat; sumatriptan nasal spray approved ≥12 years
Preventive: Pizotifen 0.5 mg nocte (titrate to 1.5 mg) — PBS general benefit; propranolol 1 mg/kg/day; amitriptyline 0.25–1 mg/kg nocte
Red flags: Morning headache with vomiting, headache worsening with bending/coughing, macrocephaly, precocious puberty → urgent neuroimaging
Elderly (≥65 years)
Key concern: New-onset headache in elderly is secondary until proven otherwise — exclude GCA, mass lesion, medication side effects
GCA red flags: Temporal headache, jaw claudication, visual symptoms, ESR >50 → start prednisolone immediately
Medications: Avoid NSAIDs (GI bleed risk); propranolol relatively contraindicated in COPD/heart failure; candesartan or amitriptyline preferred
Diagnostic mimic: Late-onset migraine with aura vs TIA — migraine aura evolves over minutes; TIA is sudden
Renal Impairment
Acute: Paracetamol safe; avoid NSAIDs if eGFR <30; sumatriptan use with caution if severe impairment
Preventive: Propranolol and candesartan (with monitoring) preferred; avoid topiramate if eGFR <30; gabapentin/pregabalin require dose adjustment
Dialysis: Refer to nephrology for medication clearance guidance
Hepatic Impairment
Acute: Paracetamol at reduced dose (max 2 g/day in severe impairment); avoid codeine/combination analgesics
Preventive: Propranolol — reduced first-pass metabolism; start low. Avoid sodium valproate. Topiramate — use with caution
Investigation: Consider hepatic encephalopathy as cause of headache in cirrhosis
Immunocompromised
High suspicion: Cerebral abscess, cryptococcal meningitis, toxoplasmosis, PML (JC virus), CNS lymphoma
Investigation: Low threshold for MRI with contrast and lumbar puncture (after CT head to exclude raised ICP)
HIV-specific: Cryptococcal meningitis — amphotericin B + flucytosine induction; consult infectious disease
Post-transplant: Consider opportunistic infections and calcineurin inhibitor neurotoxicity
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
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