Episode 195: Case of headache.     

Future doctors Ibrahim and Redden explain the most common causes of headaches and explain the features of a serious cause of headache. Dr. Arreaza highlights the importance of diagnosis migraines.   

Written by Michael Ibrahim, MSIV, and Jordan Redden, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD.

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Dr. Arreaza: 
Our topic today is one every doctor will commonly see in their practice: headaches. Headache is one of the most common neurological complaints encountered in clinical practice and affects people of all ages and backgrounds. I have learned that a headache can be “the noise of a working brain” or it can be a cue to a more serious condition. So, let’s start at the beginning: Michael, give us the big picture: how should clinicians think about headaches?

Michael:
Sure thing, Dr. Arreaza. So, at its core, a headache is pain that’s felt in the head, scalp, or neck. But that’s just the surface. Clinically, we break headaches into two broad categories: primary and secondary. Primary headaches are their own condition: things like migraines, tension-type headaches, or cluster headaches. Secondary headaches, on the other hand, are a symptom of something else: an infection, trauma, vascular event, or even a brain tumor.

The challenge for us as clinicians is distinguishing between the two. Because while most headaches are benign, some can signal something much more serious. That’s why a detailed clinical history and a careful neurologic exam are absolutely essential.

Jordan:
Exactly. We were taught that while not every headache needs imaging, every headache needs a detailed history. Understanding the timeline, triggers, and associated symptoms can really point you in the right direction.

Dr. Arreaza:
Great points. Let's move into a real-world scenario. Michael, tell us about the patient case you brought to the podcast.

Michael:
Right. Our patient is a 32-year-old woman, Ms. A., who’s had six months of intermittent, throbbing headaches. They’re mostly on the right side, and they come with nausea, sensitivity to light and sound. She notices they’re often triggered by stress, poor sleep, or skipping meals. Her neuro exam is normal, but she’s anxious; she fears it might be a brain tumor.

Jordan:
That’s such a common scenario. Even when the clinical picture strongly suggests migraine, patients often fear the worst. And honestly, given how disabling migraine attacks can be, their concern is totally valid.

Dr. Arreaza: 
Exactly. We should never downplay the patient’s fear. And in Ms. A’s case, the symptoms: unilateral throbbing, photophobia, nausea; these really do fit the classic migraine profile. Let’s review the major types of headaches.

Michael:
So, we break headaches down into primary and secondary. Under primary headaches, you’ve got migraines (with or without aura), tension-type headaches, which are the most common, and cluster headaches, which are rarer but incredibly distinctive.

Jordan:
When it comes to secondary headaches, we must think broadly. There are infectious causes like meningitis or encephalitis, vascular emergencies like subarachnoid hemorrhage, temporal arteritis in older adults, tumors, trauma, and even medication overuse.

Dr. Arreaza:
Let’s pause on that one: medication overuse. That’s a headache many patients don’t expect. They’re trying to manage their pain, but if they use analgesics too frequently (especially things like triptans, combination pain meds, or opioids) they can actually perpetuate the cycle of pain.

Michael:
It’s a vicious loop. Patients take more meds to control their headaches, but the rebound from those meds keeps the headache going. That’s why we always ask, how often are you taking something for your headache?

Dr. Arreaza:
That’s right. What are the clinical clues that would help us figure out the type of headache we’re dealing with?

Michael:
Well, migraines typically present with a combination of features: moderate to severe pain, often unilateral and throbbing, worsened by activity, and associated with nausea or vomiting and light or sound sensitivity. If there's an aura: visual changes, sensory symptoms, or speech disturbance, that can help confirm the diagnosis.

Dr. Arreaza: 
Let’s remember the POUND mnemonics. Pulsating, throbbing, or varying the heartbeat. One to three days (4-72 h in duration). Unilateral location, usually frontotemporal. In children, it is often bilateral and switches to unilateral in adolescence. Nausea/Vomiting AND/OR Photophobia/Phonophobia. Disabling intensity: moderate to severe in intensity and it get worse with movement. Migraines hate movement! According to AFO Journal, “In a primary care setting, the probability of a migraine is 92% in patients who report at least four of the five POUND symptoms. The probability decreases to 64% in patients with three of the symptoms, and 17% in patients with 2 or fewer symptoms.”

Jordan:
Now, cluster headaches have previously been referred to as “suicide headaches” because the pain is so intense. They’re usually one-sided, come in cycles or “clusters,” and are associated with autonomic features like tearing, nasal congestion, even ptosis or miosis, which could mimic Horner’s syndrome.

Michael:
Tension-type headaches, on the other hand, feel more like a tight band around the head. They're bilateral, pressing rather than pulsating, and usually not accompanied by nausea or sensory sensitivity.

Jordan:
And then we always keep red flags in mind. That’s where the SNOOP mnemonic helps: Systemic symptoms, Neurologic signs, Onset sudden, older age, and Pattern change. These mnemonics have been updated, and several items have been added. It has two Ns, 2 Os, and 10 Ps. For example, one of the Ns that is added is neoplasia history, and some of the Ps are Pregnancy/Postpartum, Papilledema, and Pain killer overuse. You can find the updated version in the American Family Physician journal, April 2025. 

Dr. Arreaza:
Exactly. Any of those should raise alarm bells. “Thunderclap headaches” especially! Those need immediate evaluation. I learned it in med school as “a lightning flashing in a blue sky” (Hispanics drama is real, folks [joke]).

Michael:
If we’re worried about secondary causes, that’s when labs and imaging come in. We might check CBC for infection, ESR for temporal arteritis, or even a toxicology screen if substances are a concern.

Jordan:
And imaging! Non-contrast CT is great for acute or sudden-onset headaches. But for chronic or worsening symptoms, we lean toward MRI. If vascular causes are on the table, we might add MRV or CTA. And don’t forget lumbar puncture if we’re thinking about meningitis or subarachnoid hemorrhage.

Dr. Arreaza:
Very good. The key is to tailor the workup to clinical suspicion. Not every headache needs a CT, but some definitely do. It’s not just about getting tests, it’s about getting the right tests based on the story. Let’s talk about management. How do we approach treatment?

Michael:
For acute migraine attacks, NSAIDs are a good first-line. Triptans are also effective, especially if given early. And adding an anti-emetic like metoclopramide can help with both nausea and improve absorption of oral meds.

Jordan:
And for tension-type, it’s usually NSAIDs, sometimes acetaminophen. But non-pharmacologic measures are key too, things like stress reduction, sleep hygiene, posture correction, etc.

Michael:
Cluster headaches are a different beast. The go-to is high-flow oxygen, 15 L via non-rebreather mask, and subcutaneous sumatriptan, because oral meds are too slow.

Jordan:
An even bigger challenge is treatment when headaches become chronic, especially with medication overuse. And there’s often comorbidity with depression or anxiety, which complicates management.

Michael:
Fortunately, most people with headaches don’t have chronic headaches. Some risk factors for chronic headaches include family history, female sex, poor sleep, stress, and hormonal shifts. Triggers like caffeine, dehydration, and irregular meals are also common.

Dr. Arreaza:
Those elements are important to ask about during the visit, not just the headache itself, but what might be feeding into it.

Jordan:
For patients with frequent headaches, preventive therapy is a game-changer. Think things like beta-blockers, topiramate, amitriptyline, or CGRP inhibitors. Gepants and ditans are newer medications, supported by evidence as second-line agents. Unlike triptans and ergot alkaloids, gepants and ditans do not have vascular contraindications. Their use may be limited by cost.

Michael:
And we can’t forget lifestyle modifications. Encouraging regular sleep, hydration, and stress reduction often makes an enormous difference.

Dr. Arreaza:
To wrap it up: headaches are complex, but with a structured approach, we can distinguish benign from dangerous. Michael, any final takeaway?

Michael:
Yes! Start with a good history and physical, then build your differential. Most headaches are manageable, but don’t ignore red flags.

Jordan:
And always validate the patient’s concerns. Even if it’s “just a migraine,” it can be disabling, and we need to treat it seriously. 

Dr Arreaza:
Thanks for listening! Stay tuned for our next episode!

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References: 

1. International Headache Society. (2018). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Retrieved fromhttps://ichd-3.org/ 

1. Dodick, D. W. (2003). Clinical clues and clinical rules: Approach to the diagnosis of secondary headache. Headache: The Journal of Head and Face Pain, 43(3), 282–292.https://doi.org/10.1046/j.1526-4610.2003.03057.x 

1. American College of Radiology. (2019). ACR Appropriateness Criteria® Headache. Journal of the American College of Radiology, 16(5S), S364–S377.https://doi.org/10.1016/j.jacr.2019.02.008 

1. Taylor, F. R., & Kaniecki, R. G. (2011). Symptomatic treatment of migraine: When to use NSAIDs, triptans, or opiates. Current Treatment Options in Neurology, 13(1), 15–27.https://doi.org/10.1007/s11940-010-0103-9 

1. Gilmore B, Michael M. Treatment of acute migraine headache. Am Fam Physician. 2011 Feb 1;83(3):271-80. Erratum in: Am Fam Physician. 2011 Oct 1;84(7):738. PMID: 21302868. https://pubmed.ncbi.nlm.nih.gov/21302868/

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