How to Approach Headache: From Migraine to Life-Threatening Causes

“It was just my usual headache — or so I thought.”
To prevent life-threatening conditions from being overlooked, what should we ask in the history? What should we look for in the physical exam?
In this article, we’ll break down how to differentiate primary headaches like migraine and tension-type, from dangerous secondary headaches such as subarachnoid hemorrhage and temporal arteritis.
You’ll learn a step-by-step approach—from history and physical exam to diagnostic workup—useful for OSCEs and real-life practice.

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🎯 What You Will Learn in This Article

• How to distinguish primary headaches (e.g., migraine, tension-type) from dangerous secondary causes
• How to identify red flags (SNOOP) and physical exam findings that require urgent workup
• Essential questioning and examination techniques for OSCE and real-world encounters—with English phrases included

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🧑‍⚕️ Case Introduction: Is This Just a Migraine?

🪪 Doorway Information
32-year-old woman / Chief complaint: Headache / Vitals: T 36.8℃, BP 116/74 mmHg, HR 72/min, SpO₂ 98%, GCS 15

🗣 Patient’s Words
“I’ve had this throbbing pain on the left side of my head for the past 2–3 days. Bright lights hurt my eyes, I feel nauseated, and even lying down doesn’t help.
I do get stiff shoulders sometimes and I haven’t been sleeping well, so I thought that might be the reason…”

At first glance, it sounds like a classic migraine. But is it really?

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🧭 First Impression: Primary or Secondary Headache?

The patient reports unilateral, throbbing pain with photophobia and nausea—features that strongly suggest migraine.
However, we must always begin by asking: “Is this really a primary headache?”

Primary headaches (like migraine, tension-type, and cluster headaches) are benign and not caused by underlying disease.
In contrast, secondary headaches result from other medical conditions—some of which may be life-threatening if missed.

That’s why the first priority is to screen for Red Flags.

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🚩 Don’t Miss the Red Flags: Use “SNOOP”

Whenever evaluating a headache, it’s essential to rule out secondary causes.
The “SNOOP” mnemonic helps you identify dangerous features:

Letter	Category	Details
S	Systemic signs	Fever, weight loss, history of cancer or immunodeficiency
N	Neurologic signs	Paralysis, diplopia, seizure, altered mental status
O	Onset	Sudden (“thunderclap”) headache
O	Older age	New headache onset after age 50
P	Pattern change	New type, progressive, or first-ever headache

If any of these features are present, consider imaging and further evaluation to rule out a secondary cause.

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⏱️ Don’t Forget the Time Course

When did the headache start, and how fast did it peak? These details are key:

• Acute onset: Subarachnoid hemorrhage (SAH), meningitis, acute glaucoma
• Chronic: Migraine, tension-type, brain tumor, sinusitis
• Recurrent: Migraine, cluster headache

Thunderclap headache (sudden and severe, peaking within a minute) is a neurological emergency. Always consider a CT scan.

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📍 Location Clues Can Help

Location	Likely Cause
Frontal or Unilateral	Migraine
Occipital or Bilateral	Tension-type headache
Periorbital	Cluster headache, glaucoma, sinusitis
Temporal (elderly)	Giant cell arteritis (GCA)

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🩺 Dangerous Mimics You Must Not Miss

Even when a headache seems benign, always keep these life-threatening causes in mind:

• Subarachnoid hemorrhage (SAH)
• Giant cell arteritis (GCA)
• Brain tumor
• Meningitis
• Acute glaucoma
• Hypertensive encephalopathy
• Carbon monoxide (CO) poisoning – especially during winter, with family members also affected

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🧱 Column｜When the Whole Family Has a Headache in Winter… Think CO Poisoning

Carbon monoxide (CO) is colorless, odorless, and non-irritating—making it a silent killer.
It results from incomplete combustion, especially in poorly ventilated, heated spaces.

🧪 CO Levels and Symptoms

CO Level (ppm)	Exposure Duration	Symptoms
50 ppm	Several hours	Mild headache, fatigue
200 ppm	2–3 hours	Throbbing headache, dizziness, nausea
400 ppm	1–2 hours	Severe headache, altered consciousness
800 ppm	< 45 minutes	Coma, seizures
1600 ppm	< 20 minutes	Lethal

🔬 Pathophysiology: Mitochondrial Dysfunction

CO binds to hemoglobin but also inhibits Complex IV (cytochrome c oxidase) in the mitochondrial electron transport chain,
leading to impaired ATP production and tissue hypoxia at the cellular level.

🧠 Be Aware of Delayed Neurological Sequelae (DNS)

Even after initial improvement, patients may develop memory loss, personality changes, or motor symptoms days later.
This is likely due to ischemia and inflammatory demyelination—not just redistribution.

💡 Key Message

If CO poisoning is suspected: ventilate immediately, give 100% oxygen, and check SpCO or arterial blood gas (ABG).

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🧠 How to Reason Through a Headache: Start with Fact–Problem–Hypothesis

By now, it’s clear that jumping to “It’s just a migraine” is risky.
Let’s revisit our case and walk through the reasoning step by step.

🩺 Doctor–Patient Conversation

Doctor: “What brings you in today?”
Patient: “For the past 2–3 days, I’ve had this throbbing pain on the left side of my head.
Bright lights hurt my eyes, I feel nauseated, and even resting doesn’t help…”

💭 Internal Monologue

“Hmm… throbbing, one-sided pain with photophobia and nausea—sounds like a classic migraine.
But is this her first time? Is it different from her usual headaches?
I need to rule out red flags before assuming it’s benign.”

🧾 Fact – Problem – Hypothesis

• ✔ Fact (What the patient says):
  • 30s female
  • Throbbing left-sided headache for 2–3 days
  • Photophobia, nausea, worsens at rest
• ✔ Problem (What we define clinically):
  • Unilateral, pulsating pain with light sensitivity and nausea—migraine features
  • But unclear onset pattern (sudden vs gradual), unclear if this is a “new” or “different” headache
  • No mention yet of fever, focal deficits, or visual changes
• ✔ Hypothesis (Expand with VITAMIN CDE):
  

  Category	Possible Diagnoses
  Vascular	SAH, cerebral venous thrombosis, hypertensive encephalopathy
  Infection/Inflammation	Meningitis, GCA
  Trauma	Chronic subdural hematoma
  Autoimmune	CNS vasculitis, SLE-related headache
  Neoplastic	Brain tumor (morning, progressive)
  Congenital	AVM (possible SAH in young patients)
  Degenerative	Glaucoma (visual field loss, eye pain)
  Endocrine/Metabolic	CO poisoning, PMS, pregnancy-related migraine, hyponatremia, hypercapnia

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📝 NTK (Need to Know): What to Clarify in the History

Category	What to Ask	Rationale
HPI details	Is this the first time? Sudden or gradual?	Assess for thunderclap or new-onset headache
Associated symptoms	Fever, nuchal rigidity, visual changes, weakness, seizures	Signs of infection, hemorrhage, mass effect
Medications / Past History	Oral contraceptives, glaucoma, SLE	Risk of CVT, inflammatory or autoimmune disease
Environment	Closed winter room, family also unwell?	Suspect CO poisoning
Social context	Stress, sleep, screen time	VDT-related or tension-type headache
Menstrual cycle	Timing in relation to period?	Possible hormonally triggered migraine

Even if symptoms point to migraine, be sure to keep red flags in mind and proceed systematically with history and physical exam.

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🩺 Step 1: History Taking – Master Two Key Frameworks

Let’s now shift from the case to a general approach.
For any patient presenting with headache, we recommend combining:

• OPQRST: To characterize the pain
• PAM HITS FOSS: To identify background risks and red flags

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🧭 OPQRST: Characterize the Pain

Item	Example Questions	Clues
O (Onset)	When did it start? Was it sudden?	Thunderclap → SAH
P (Palliative / Provocative)	What makes it better or worse?	Dark room helps → Migraine / Bending worsens → Sinusitis
Q (Quality)	What does it feel like? Throbbing? Tight?	Throbbing → Migraine / Tight → Tension-type
R (Radiation)	Does it spread anywhere?	To eyes or neck → Consider cluster, meningitis
S (Severity)	How bad is the pain (0–10)? Can you function?	Severe → Consider migraine or emergency
T (Timing)	How long does it last? How often?	4–72 hrs → Migraine / Cyclic → Cluster

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📋 PAM HITS FOSS: Check Risk Factors Thoroughly

Item	What to Ask	Relevant Conditions
Previous / Past History	History of migraine, glaucoma, SLE	Glaucoma, GCA, CNS disorders
Allergy	NSAIDs, triptans	May limit treatment options
Medications	OCPs, beta blockers, antidepressants	CVT, medication-induced headaches
Hospitalization	Stroke, trauma history	Chronic subdural hematoma
Injury	Recent head injury?	Delayed subdural bleeding
Trauma (psychological)	Stress, grief, mental health	Tension-type, migraine triggers
Surgery	Eye or brain surgery	Glaucoma, optic neuropathy
Family history	Headache, stroke	Genetic risk
OBGYN	Menstrual cycle, pregnancy	Hormonal migraine
Sexual history	STIs, HIV risks	Meningitis, HIV-related CNS disease
Social history	Smoking, sleep, occupation, stress	VDT syndrome, tension-type headache

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💡 Tip: Digital Eye Strain & VDT Syndrome

Long hours at a computer or phone can lead to Digital Eye Strain (DES), also known as Computer Vision Syndrome (CVS).
Common signs include:

• Headache that worsens in the evening
• Eye fatigue, shoulder tension, dry eyes
• Poor posture and inadequate breaks during screen time

These are key clues for tension-type or visual fatigue headaches.

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💡 Tip: Screening Tools for Migraine

• ICHD-3: Official diagnostic criteria
  🔗 ichd-3.org
• ID Migraine™ Screener: 3-question tool (light sensitivity, nausea, activity limitation)
  🔗 PubMed (Lipton 2003)
• MIDAS: Disability scale based on daily life impact
  🔗 MIDAS PDF
• HIT-6: 6-item questionnaire assessing headache impact on quality of life
  🔗 headachetest.com

These tools can support both diagnosis and treatment planning.

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🔍 Step 2: Physical Examination – Don’t Miss Red Flags from Head to Toe

Once red flags are suspected based on history, we move on to focused physical examination.
Don’t just “look around”—evaluate systematically with the goal of ruling in or out specific dangerous causes.

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🧠 Systematic Red Flag Assessment: General + Neurological + Ocular

Exam Area	What to Check	Possible Diagnosis
Consciousness & posture	Drowsiness, abnormal posture, GCS	SAH, meningitis, brain tumor
Eye movement & visual fields	Diplopia, vision loss, CN palsies	Glaucoma, tumor, increased ICP
Fundoscopy	Papilledema, optic disc pallor, retinal hemorrhage	Raised ICP, optic neuritis
Temporal artery palpation	Thickening, tenderness, weak pulse	Giant cell arteritis (GCA)
Neck stiffness (Kernig / Brudzinski)	Signs of meningeal irritation	Meningitis, SAH
Neurological findings	Hemiparesis, sensory loss, ataxia, seizure	Stroke, CNS infection
Vital signs	Fever, hypertension with bradycardia, tachypnea	Infection, Cushing’s triad, CO poisoning

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💡 Tip: Don’t Forget the Sinuses

Sinusitis can mimic migraine or tension-type headache.
Key features include:

• Frontal or midface heaviness
• Facial tenderness, sinus pressure
• Purulent nasal discharge, postnasal drip
• Maxillary tooth pain (esp. in maxillary sinusitis)

Examination points:

• Palpate frontal/maxillary sinuses for tenderness
• Percuss sinus bones gently (pain = possible inflammation)
• Inspect nasal mucosa for swelling or discharge (if feasible)
• Look for facial redness or swelling (consider cellulitis)

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💡 Tip: Eye Pressure & Otoscopy Are Also Important

👁️ Intraocular Pressure (Tonometry)

Acute angle-closure glaucoma may cause severe eye pain, headache, vomiting, and vision loss.
If the eye is tender to touch and IOP > 20 mmHg (especially > 30 mmHg), act urgently.

👂 Otoscopy

Otitis media or mastoiditis can present as unilateral headache with fever and ear symptoms.
Check for:

• Red, bulging tympanic membrane
• Middle ear effusion or immobility
• Canal swelling, tragal tenderness (otitis externa)
• Swelling and tenderness behind the ear (mastoiditis)

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💡 Topics: Trigger Points in Tension-Type Headache

Muscle	Referred Pain Area	Exam Focus
Upper trapezius	Occipital, temporal, orbital	Shoulder top, neck base
Sternocleidomastoid (SCM)	Forehead, temple, behind eyes	Below ears to clavicle
Suboccipital muscles	Occipital area, behind eyes	Tenderness near C1–C2
Temporalis	Temple, jaw, teeth	Reproducible tenderness at temple
Masseter	TMJ, cheek, preauricular area	Tender near jaw angle and cheek center

Ask: “Does pressing here bring on the same headache pain?”
Reproducible tenderness may help confirm a myofascial component.

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🧱 Column｜Hypertensive Emergency and Headache

Hypertensive emergency = BP ≥180/120 mmHg + end-organ damage
Hypertensive urgency = BP ≥180/120 mmHg without organ damage

Common causes:

• Stroke, hypertensive encephalopathy
• Aortic dissection
• Heart failure, pulmonary edema
• Renal failure, glomerulonephritis
• Preeclampsia, eclampsia (HELLP)

Red flag headache patterns:

• Pulsatile headache + visual symptoms → suspect encephalopathy
• Sudden, severe headache + focal deficit → suspect hemorrhagic stroke

Investigations:

• Bilateral BP, urinalysis (protein, hematuria)
• Fundoscopy (retinal hemorrhage, edema)
• Head CT if hemorrhage or cerebral edema suspected
• Blood tests (renal function, electrolytes, LDH, platelets)

⚠️ Note: Avoid rapid BP lowering in some cases (risk of ischemia). Gradual reduction is key.

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🔬 Step 3: Investigations and Imaging – Test With a Clear Hypothesis

Once your clinical hypothesis is in place, choose investigations based on what you’re trying to confirm or rule out.
Avoid a “just-in-case” CT or MRI. Instead, ask: Is it a red flag? Organ dysfunction? Structural issue? Infection?

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🧪 Common Tests and Their Purposes

Test	Purpose	Suspected Condition
Non-contrast head CT	Detect hemorrhage or mass lesion	SAH, tumor, ICH
Brain MRI / MRA	Visualize ischemia, malformations, vasculitis	CVT, CNS vasculitis, tumors
Lumbar puncture	Rule out meningitis or SAH (when CT is negative)	Meningitis, late SAH
Fundoscopy	Detect papilledema, optic neuritis	Increased ICP, optic nerve involvement
Tonometry	Check for glaucoma	Glaucoma-induced headache
Blood tests (CBC, CRP, ESR)	Assess for infection, inflammation, vasculitis	Meningitis, GCA, malignancy
Procalcitonin (PCT)	Differentiate bacterial vs viral infection	Meningitis, abscess
Temporal artery ultrasound	Look for halo sign	GCA
Sinus CT	Evaluate for sinusitis	Acute or chronic sinusitis

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🧠 Thought Process Examples

• “Sudden, severe headache → Get a CT first to rule out SAH.”
• “If CT is negative and SAH is still likely → Do LP.”
• “Elderly with temple pain → Check CRP/ESR and consider temporal artery ultrasound.”
• “Visual symptoms or ocular pressure → Do tonometry or refer to ophthalmology.”
• “Dull pain with no neuro findings → Consider sinus CT.”

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⚖ CT vs MRI – When to Use Each

Feature	CT	MRI
Speed	Fast (minutes)	Slow (30+ minutes)
Best for	Bleeds, mass lesion	Ischemia, small lesions, vasculitis
Setting	Emergency, SAH, AMS	Outpatient, detailed diagnosis
Limitations	May miss small strokes or meningitis	Not always feasible (metal, motion, cost)

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🩺 Lumbar Puncture (LP) – Indications and Cautions

• Indications:
  • Suspected meningitis
  • Suspected SAH with negative CT (esp. >6 hours from onset)
• Caution:
  • Don’t perform LP if signs of increased ICP (e.g. papilledema)
  • Always do CT first to avoid risk of brain herniation

LP is often the “last resort” to exclude dangerous causes when all else is inconclusive.

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🧪 Additional Blood Tests to Consider

• CRP / PCT: Helps differentiate bacterial vs viral infections
• ESR: Elevated in GCA (e.g. >50 mm/h)
• Serum Na: Hyponatremia may cause headache, confusion, seizures
• COHb: If CO poisoning is suspected, check SpCO or ABG

Every test should follow the flow: Hypothesis → Testing → Clinical Decision.

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🧩 Step 3.5: If No Red Flags – Consider Primary Headaches

If your history, physical exam, and investigations rule out secondary causes, consider primary headache disorders.

Though not life-threatening, they can severely impact quality of life. Proper classification helps guide treatment and education.

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🔎 The Big 3: Primary Headache Types

Type	Examples	Key Features
① Migraine	With aura / Without aura	Throbbing, unilateral, photophobia, nausea, lasts hours to days, disabling
② Tension-type headache (TTH)	Frequent / Chronic	Bilateral, pressing/tight, mild to moderate, linked to stress or posture
③ Trigeminal autonomic cephalalgias (TACs)	Cluster, PH, SUNCT, SUNA	Severe periorbital pain, autonomic symptoms (tearing, nasal congestion)

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📋 Clinical Features and Diagnosis Tips

• Migraine: Pulsatile, unilateral, worsens with activity, often with nausea or photophobia. Aura may include visual disturbances or paresthesia.
• Tension-type: Bilateral “band-like” tight pain, not aggravated by routine activity. Often linked to poor posture or prolonged screen time.
• Cluster: Excruciating pain around one eye, comes in clusters (e.g. same time daily), with red eye, tearing, or nasal symptoms.

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💡 Tip: TACs Overview (Trigeminal Autonomic Cephalalgias)

Type	Duration	Frequency	Treatment	Note
Cluster	15–180 min	1–8/day	O₂, triptans, verapamil	Nighttime attacks, cluster periods
Paroxysmal Hemicrania (PH)	2–30 min	Several/day	Indomethacin	Dramatic response is diagnostic
SUNCT	5–240 sec	Dozens–hundreds/day	Lamotrigine, topiramate	Red eye + short bursts
SUNA	Seconds–minutes	Less frequent	Same as SUNCT	Lacks tearing or nasal symptoms

Clinical pearl: Always consider TACs in short, frequent headaches with eye symptoms. SUNCT/SUNA are often misdiagnosed as cluster.

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🛠 What to Do After Diagnosing Primary Headache

• Acute treatment: NSAIDs, triptans, oxygen (for cluster)
• Prophylaxis: If ≥4 attacks/month, or acute meds ineffective
  • Beta blockers (e.g., propranolol)
  • Antiepileptics (e.g., valproate, topiramate)
  • Calcium channel blockers (e.g., lomerizine)
  • TCAs (for chronic TTH)
  • CGRP inhibitors (e.g., erenumab) for high-frequency migraine
• Lifestyle guidance: sleep, hydration, avoid triggers (wine, cheese, stress)
• Headache diary: Record patterns, triggers, medication responses

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🧱 Column｜Why Do Wine and Cheese Trigger Headaches?

Many patients report that red wine or cheese triggers their migraine. The common culprit? Tyramine.

🔬 What is Tyramine?

• Derived from amino acids (natural monoamine)
• Found in aged/fermented foods (cheese, wine, cured meats)
• Causes vasoconstriction followed by reflex vasodilation, triggering headache

🧠 Tyramine and Headache Link

• Stimulates norepinephrine release → vascular instability
• Typical in “delayed-onset” headaches after eating
• Only affects sensitive individuals

📋 Education Tips

• Encourage a headache diary to track food triggers
• If a clear link is seen, advise dietary modification

⚠️ Tyramine Toxicity with MAOIs

If a patient is taking monoamine oxidase inhibitors (MAOIs), tyramine cannot be metabolized → hypertensive crisis risk.

• Mechanism: Excess norepinephrine → sudden BP spike
• Symptoms: Severe headache, visual changes, sweating, risk of stroke
• Avoid: Aged cheese, wine, fermented foods, cured meats, soy products

Summary: Migraine + wine = dietary trigger
MAOIs + wine = life-threatening hypertensive emergency

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🔁 Revisit the Case Step-by-Step

Now that we’ve reviewed Steps 1–3 of headache evaluation, let’s apply them to our original case—one step at a time.

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🟦 Step 1: History Taking (Fact → Problem → Hypothesis)

Doctor: “What brings you in today?”
Patient: “For the past 2–3 days, I’ve had a throbbing headache on the left side. Light bothers me, I feel nauseated, and even lying down doesn’t help…”

💭 Thought: “Sounds like a classic migraine—but I need to confirm there’s no red flag. Ask about onset, severity, and any visual or neurological symptoms.”

🔎 OPQRST

• O: Gradual onset over a few days
• P: Improves in dark room, worsens with movement
• Q: Throbbing pain
• R: Left-sided, radiating to the eye
• S: 8/10; interferes with daily life
• T: Preceded menstruation; worst episode so far

📋 PAM HITS FOSS

• History of mild headaches, but this is most severe
• On low-dose oral contraceptives; family history of migraine
• Desk work 8+ hours/day; recent sleep deprivation and stress

🧠 Hypothesis

• Most likely: Migraine without aura
• Need to rule out: SAH, CVT, glaucoma, GCA, CO poisoning

📋 ID Migraine™ Screener

• Light sensitivity → Yes
• Nausea or vomiting → Yes
• Disruption to daily activities → Yes

Score: 3/3 → Positive screening for migraine (sensitivity 81%, specificity 75%)

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🟦 Step 2: Physical Exam

• Clear consciousness, GCS 15
• No focal neurological deficits
• No neck stiffness, visual disturbance, or eye pressure pain
• Normal temporal arteries (no tenderness or thickening)

→ No red flag findings on physical exam.

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🟦 Step 3: Diagnostic Workup

• Head CT: No hemorrhage or mass lesions
• Eye pressure: Normal (18 mmHg)
• Blood tests: Normal CRP, PCT, ESR

→ No signs of secondary headache. Primary headache diagnosis (migraine) confirmed.

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🧭 Conclusion: With no red flags and a typical presentation, this is consistent with migraine without aura.

Now, let’s explore how non-specialists can effectively manage migraine and educate patients on prevention strategies.

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💡 Practical Management of Migraine for Generalists

Migraine significantly impacts quality of life, but many cases can be managed effectively in primary care.
Understanding the difference between “with aura” and “without aura” is crucial, as it affects diagnosis, treatment, and risk assessment.

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🔍 Two Types of Migraine (ICHD-3 Classification)

• 1.1 Migraine without aura – Most common; no warning signs
• 1.2 Migraine with aura – Visual, sensory, or speech-related symptoms precede the headache

🔬 Pathophysiology

• With aura: Involves cortical spreading depression (a wave of neuronal suppression)
• Without aura: Related to trigeminal nerve activation and release of inflammatory peptides

⚠️ Migraine with aura is associated with a higher risk of ischemic stroke, especially in women taking oral contraceptives.

⏳ Patients may switch between types over time, so always reassess if symptoms change.

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🚑 Acute Migraine Treatment

• Mild–moderate: NSAIDs (e.g., loxoprofen, acetaminophen)
• Moderate–severe: Triptans (e.g., sumatriptan, zolmitriptan)
• With nausea/vomiting: Add antiemetics (e.g., metoclopramide, domperidone)

⚠️ Triptans overused more than 10 days/month may cause medication overuse headache (MOH).

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🛡 When to Start Preventive Therapy

• ≥4 attacks per month
• Acute meds are ineffective or poorly tolerated
• Severe impact on daily life or work

🧪 Common Prophylactic Agents

• Beta blockers: propranolol
• Antiepileptics: valproate, topiramate
• Calcium channel blockers: lomerizine
• Tricyclic antidepressants: amitriptyline (esp. for chronic TTH)
• CGRP monoclonal antibodies: e.g., erenumab (for refractory cases; insurance limitations apply)

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📘 Lifestyle & Patient Education

📌 Common Migraine Triggers

• Sleep disturbance (too little or too much)
• Dehydration or skipping meals
• Hormonal changes (e.g., menstruation)
• Stress, weather or barometric changes
• Dietary: red wine, cheese, chocolate

📝 Practical Guidance

• Use a headache diary to identify patterns and triggers
• Hydrate (≥2L/day), eat and sleep regularly
• Manage screen time and posture (for VDT-related headaches)
• Incorporate stretching and stress management

💬 Key Messages to Patients

• “Migraine is a manageable condition.”
• “Prevention involves both medication and lifestyle.”
• “Seek immediate care if you experience red flags like paralysis, fever, or sudden severe headache.”

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🧭 Now let’s consider: When should we refer patients with headache to a specialist?
What should we prepare before making that referral?

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🏥 When to Refer to a Specialist

Most headaches can be managed in primary care, but certain situations warrant referral to neurology or other specialists.

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📌 Indications for Referral

• Presence of red flag symptoms (e.g., thunderclap onset, fever, focal neurological deficits, vision loss)
• Refractory migraine (insufficient response to acute and preventive therapy)
• Chronic daily headache (≥15 days/month), or suspected medication overuse headache (MOH)
• Possible structural brain lesion (e.g., tumor, vascular malformation)
• New headache with neurological findings (e.g., hemiparesis, aphasia, visual field defect)
• Suspected CSF leak or intracranial hypotension (orthostatic headache)
• Severe anxiety or strong patient request

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🧾 What to Prepare Before Referral

Clear documentation will help the specialist make timely and accurate decisions.

• Detailed history: Onset, frequency, duration, triggers, associated symptoms (OPQRST)
• Past medical & medication history: especially anticoagulants, OCPs
• Neurological exam findings: motor, sensory, reflexes, papilledema, cranial nerves
• Imaging results: Head CT/MRI with reports (if already performed)
• Blood tests: CRP, ESR, CBC, electrolytes
• Questionnaire results: ID Migraine, MIDAS, headache diary (if available)

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💡 Tips Before Referral

• Check eye pressure: Rule out glaucoma
• Perform otoscopy: Exclude otitis or mastoiditis
• Palpate neck and sinuses: Consider myofascial or sinus headache
• Educate patients: Reassure that many headaches are benign and manageable

Preparing these items ensures a smoother handoff and helps reduce patient anxiety.

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🩺 Clinical Tips & Pearls

✅ Practical Tips for History and Physical Exam

• Always ask: “When did it start?” and “How did it begin?” — This helps catch thunderclap onset early.
• Ask: “Is this headache the same as usual?” — A key question to rule out secondary causes.
• Don’t skip: Fundoscopy, tonometry, otoscopy, and sinus percussion. These simple tools help detect glaucoma, infection, or sinusitis.
• Be specific: Ask about location (frontal / temporal / occipital / orbital / neck).
• If patients struggle to describe aura, offer options: “Do you see flickering lights or zigzag lines?”
• Evaluate trigger points: Trapezius, SCM, suboccipital, temporalis, masseter
• For VDT-related headaches, ask about screen time, posture, and eye strain
• Review headache diaries together — It helps patients gain insight and track treatment effects

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💬 Clinical Pearls

“Beware of the worst headache of one’s life.”
— Emergency Medicine Proverb

“If a patient says it’s different, believe them.”
— Neurology Teaching

“Not all thunderclaps are bleeds, but all bleeds can thunder.”
— Stroke Teaching Pearl

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🗣️ OET Speaking Session – Headache (Emergency Evaluation)

👥 Scenario

You are a doctor in the emergency department. A 32-year-old woman presents with a 3-day history of left-sided, throbbing headache. She reports photophobia, nausea, and difficulty functioning. She’s concerned this might be more than “just a migraine.”

Your primary goal is to assess for red flags and determine whether this is a primary or secondary headache.

🎯 Your Task

• Clarify the characteristics of the headache (OPQRST)
• Screen for red flag features (SNOOP)
• Explain the possible diagnoses in layman’s terms
• Discuss the need for imaging or further evaluation
• Reassure the patient and give self-care advice if appropriate

💬 Sample Statements You Can Use

• “Let me ask a few more questions to understand your headache better.”
• “Have you ever had a headache like this before?”
• “We always want to make sure this isn’t something more serious, like bleeding or an infection.”
• “A scan may help us rule out any dangerous causes before we call it migraine.”
• “Even though this sounds like a migraine, we’ll check carefully to be safe.”
• “Many migraines improve with rest, hydration, and specific medication.”

💬 Common Patient Cues & Sample Doctor Responses

🧠 Challenging Questions & Sample Doctor Responses

✉️ OET Writing Task – Sample Referral Letter

Today’s Date

Dr. Caroline Lee
Neurology Department
Central General Hospital

Re: Ms. Julia Tanaka, 32 years old

Dear Dr. Lee,

I am referring Ms. Julia Tanaka, a 32-year-old woman, for neurological evaluation of a suspected migraine versus secondary headache. While her symptoms are consistent with migraine, red flag exclusion is warranted given this is her most severe episode to date.

Ms. Tanaka presented to our emergency department with a 3-day history of left-sided throbbing headache, associated with photophobia, nausea, and worsening with movement. She reported a history of milder headaches in the past, but none this intense. She is currently taking low-dose oral contraceptives and has a family history of migraine (mother).

On examination, she was alert and oriented (GCS 15) with no focal neurological deficits. Vital signs were stable. There was no neck stiffness, visual disturbance, or papilledema. A non-contrast head CT was performed, which showed no evidence of hemorrhage or mass effect. Intraocular pressure was normal, and laboratory investigations including CRP, PCT, and ESR were all within normal limits.

Although this episode most likely represents a severe migraine, I would appreciate your assessment to confirm the diagnosis and consider further management or imaging as appropriate. She is understandably anxious and would benefit from specialist input.

Thank you for your attention to this referral.

Yours sincerely,

Dr. [Your Name]
Emergency Physician

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🧭 Summary – Let the Symptom Speak

Headache is one of the most common complaints in clinical practice, but it can also be the first sign of a life-threatening condition.
That’s why a structured, stepwise approach is essential: Don’t assume “just a migraine”—listen to the symptom, and let it guide your clinical reasoning.

In this article, we reviewed how to:

• Differentially diagnose primary vs secondary headaches using red flags (SNOOP)
• Conduct targeted history-taking and physical exams (OPQRST + PAM HITS FOSS)
• Select appropriate tests based on clinical hypotheses—not guesswork
• Classify primary headaches (migraine, tension-type, TACs) and initiate treatment plans
• Handle English communication scenarios in OSCEs and real-life settings (OET Speaking & Writing)

When a patient walks in saying, “I have a headache,” take a deep breath, slow down, and start thinking:

• “Is this different from usual?”
• “Is this dangerous?”
• “What am I trying to rule out?”

🧠 Let the symptom speak. It just might save a life—

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📚 Final Differential Diagnosis Summary – VITAMIN CDE

Category	Representative Diagnoses
Vascular	Subarachnoid hemorrhage, CVT, hypertensive encephalopathy
Infectious / Inflammatory	Meningitis, temporal arteritis, sinusitis
Traumatic	Chronic subdural hematoma, post-concussion syndrome
Autoimmune	CNS vasculitis, SLE-associated headache
Metabolic / Toxic	CO poisoning, hyponatremia, medication overuse
Iatrogenic	Post-LP headache, OCP-induced CVT
Neoplastic	Brain tumor, leptomeningeal metastasis
Congenital	AVM, Chiari malformation
Degenerative	Glaucoma, cervical spondylosis
Endocrine / Other	Hormonal migraine (PMS, pregnancy), tension-type, cluster

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🔗 Related Articles

Interested in other symptom-based diagnostic guides? These articles complement your understanding of headache-related conditions:

• 🧠 Approach to Syncope and Transient Loss of Consciousness
• ⚡ Approach to Seizures and Epileptic Events
• 🌡️ Approach to Fever: From Viral Infection to Sepsis
• 🤢 Diagnosing Nausea and Vomiting: GI, Neuro, and Metabolic Causes
• 日本語版はこちら：頭痛の診断アプローチ l 一次性・二次性頭痛を見分ける方法

▶︎ See the Full Symptom-Based Approach Index

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📚 References

1. Japanese Headache Society. Clinical Practice Guidelines for Headache Disorders 2021. Igaku-Shoin.
2. Ishigami T, et al. Internal Medicine Diagnostic Manual, 3rd Edition. Igaku-Shoin.
3. Ropper AH, Samuels MA, Klein JP. Adams and Victor’s Principles of Neurology, 11th ed. McGraw-Hill Education, 2019.
4. Dodick DW. Migraine. Lancet. 2018 Jan 6;391(10127):131–144.
5. Lipton RB, et al. ID Migraine™ validation study. Neurology. 2003;61(3):375–382.
6. Institute for Healthcare Communication. English for Medical Professionals: Symptom-based Expressions. 2020.