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Neurology

Primary Headache Disorders

A framework for diagnosing migraine, tension-type headache and cluster headache clinically after screening for secondary-headache red flags and medication overuse.

In a nutshell

Primary headache is diagnosed clinically after screening for secondary red flags and medication overuse. Migraine is pulsating and sensory-sensitive, tension-type is bilateral and pressing, and cluster is short, strictly unilateral, autonomic and restless.

Classic presentation

A patient with recurrent stereotyped headache and a normal examination whose attack pattern fits migraine, tension-type or cluster headache without secondary red flags.

Key points

  • Screen every new or changed headache for thunderclap, systemic, neurological, ocular, exertional, positional and GCA red flags.
  • Use the attack pattern to classify migraine, tension-type or cluster headache.
  • Do not image a typical diagnosed primary headache solely for reassurance.
  • Treat by phenotype and prevent frequent or disabling attacks.
  • Medication overuse is a common perpetuating factor with 10-day and 15-day thresholds.

First-line investigation

Structured history, examination and headache diary; targeted tests or imaging only when the history or examination suggests a secondary cause.

Management

Exclude secondary headache

  • Identify thunderclap, systemic, neurological, ocular, positional, exertional, trauma, cancer, immune and GCA red flags before diagnosing primary headache.1,3

Classify the phenotype

  • Use laterality, quality, activity effect, associated symptoms, duration, frequency and autonomic signs to distinguish migraine, tension-type and cluster headache.1,4,5

Treat acute attacks appropriately

  • Use triptan-based treatment for migraine, simple analgesia for tension-type headache and oxygen or fast-acting triptan for cluster headache.1,7

Prevent and address medication overuse

  • Offer phenotype-specific prevention for frequent or disabling headache and withdraw overused acute medicines with support.1,6,8,9

Review pattern, function and safety

  • Use a diary, provide written advice and reassess any change in pattern, treatment failure, mood deterioration or new red flag.1,3

Exam traps

  • Thunderclap is a secondary-headache emergency until assessed.
  • Cluster patients pace and have ipsilateral autonomic signs; migraine patients commonly prefer stillness.
  • Do not use oral analgesia as acute treatment for cluster headache.
  • A normal neurological examination does not excuse ignoring a red flag.
  • Withdraw overused medication abruptly for at least 1 month and review after 4 to 8 weeks.

Key sources

  1. NICE CG150: Headaches in over 12s, recommendations (CG150, updated 3 June 2025)
  2. NICE CG150: Context (CG150 context)
  3. NHS: Headaches (NHS symptom information)
  4. NHS: Migraine (NHS condition information)
  5. NHS: Tension headaches (NHS condition information, reviewed 1 August 2025)
  6. NICE CG150: Treatment for medication-overuse headache (CG150 medication-overuse recommendations)
  7. BNF: Sumatriptan (BNF medicine monograph)
  8. BNF: Propranolol hydrochloride (BNF medicine monograph)
  9. BNF: Verapamil hydrochloride (BNF medicine monograph)
  10. BNF: Topiramate (BNF medicine monograph)
  11. BNF: Amitriptyline hydrochloride (BNF medicine monograph)
  12. MHRA: Topiramate safety measures and Pregnancy Prevention Programme (Drug Safety Update)
  13. NHS: About verapamil (NHS medicine information, reviewed 13 March 2025)
  14. NICE CG150: Update information (CG150 update, 3 June 2025)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.