10.3 Headache & Facial Pain
Key Takeaways
- Primary headache, cluster headache, and secondary headache and facial pain are the enumerated blueprint topics.
- Red flags including thunderclap onset, new headache after age 50, positional change, fever, immunosuppression, cancer and focal deficits mandate imaging.
- Triptans are contraindicated in uncontrolled hypertension and in established coronary or cerebrovascular disease.
- Medication overuse headache develops with frequent use of acute agents and requires withdrawal of the overused drug.
- New headache with jaw claudication and visual symptoms in a patient over 50 requires immediate corticosteroids for suspected giant cell arteritis.
Last updated: August 2026
Neurological disorders encompassing headache syndromes, epileptic seizures, and movement disorders constitute a major proportion of outpatient internal medicine encounters and inpatient neurology consults. Mastery of pharmacotherapy contraindications, status epilepticus emergency protocols, and the clinical features of neurodegenerative movement disorders is essential for the ABIM exam.
1. Primary & Secondary Headache Disorders
Headaches are categorized as primary (benign neurovascular syndromes) or secondary (manifestations of underlying systemic, structural, or life-threatening pathology).
Comparison of Primary Headache Syndromes
| Headache Type | Pain Characteristics & Location | Associated Clinical Features | Acute Abortive Pharmacotherapy | Evidence-Based Preventive Therapy |
|---|---|---|---|---|
| Migraine | Unilateral (60-70%), pulsating / throbbing, moderate-to-severe intensity, aggravated by physical activity (walking, climbing stairs), lasts 4-72 hours | Nausea, vomiting, photophobia, phonophobia; +/- aura (scintillating scotoma, zig-zag fortification spectra, sensory paresthesias evolving over 5-20 min, lasting <60 min) | Mild/Mod: NSAIDs, Acetaminophen, Excedrin<br/>Mod/Severe: Triptans (Sumatriptan, Zolmitriptan); Gepants (Ubrogepant, Rimegepant); Lasmiditan (5-HT 1F agonist) | Indicated if >=4 days/month or severe disability:<br/>- Beta-blockers (Propranolol, Metoprolol)<br/>- Anticonvulsants (Topiramate, Divalproex)<br/>- TCAs (Amitriptyline)<br/>- CGRP mAbs (Erenumab, Galcanezumab, Fremanezumab)<br/>- Botox (for chronic migraine >=15 days/mo) |
| Tension-Type Headache | Bilateral, pressing / tightening "band-like" non-pulsating pain, mild-to-moderate intensity, lasts 30 min to 7 days, NOT aggravated by physical activity | Pericranial muscle tenderness; NO nausea or vomiting; no more than one of photophobia or phonophobia | NSAIDs (Ibuprofen, Naproxen), Acetaminophen, Aspirin | Amitriptyline (first-line), Mirtazapine, behavioral therapy, stress management |
| Cluster Headache | Strictly unilateral, excruciating periorbital / retro-orbital / temporal pain, sharp / piercing / "hot poker", lasts 15-180 min, occurs in cyclical bouts / clusters (1-8 attacks/day, often nocturnal) | Ipsilateral cranial autonomic signs: conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, miosis, ptosis (Horner syndrome), severe agitation / pacing (unlike migraineurs who lie in a dark quiet room) | 1. 100% High-Flow Oxygen (12-15 L/min via non-rebreather mask for 15-20 min)<br/>2. Subcutaneous Sumatriptan (6 mg SC) | First-line: Verapamil (high dose: 240-960 mg daily in divided doses; monitor PR interval on serial ECGs); Prednisone bridge taper; Galcanezumab (300 mg SC) |
| Medication Overuse Headache (MOH) | Chronic daily or near-daily dull, diffuse headache present on awakening | Patient with pre-existing migraine or tension headache regularly taking acute abortive meds >10-15 days/month for >3 months | Discontinue / taper overused acute medication; initiate bridge therapy (NSAID/prednisone taper) | Early initiation of effective non-overused prophylactic agent (e.g., CGRP mAb, Topiramate, Amitriptyline) |
Migraine Pharmacology Deep-Dive
- Triptans (5-HT 1B/1D Receptor Agonists):
- Mechanism: Cause vasoconstriction of painfully distended meningeal and dural blood vessels and presynaptically inhibit the release of pro-inflammatory neuropeptides (CGRP, substance P) from trigeminal perivascular nerves.
- Critical Contraindications: Coronary artery disease (CAD), history of myocardial infarction, coronary vasospasm (Prinzmetal angina), stroke or TIA, peripheral arterial disease, uncontrolled hypertension, and hemiplegic or basilar-type migraine.
- Small-Molecule CGRP Receptor Antagonists ("Gepants"):
- Agents: Ubrogepant (50-100 mg) and Rimegepant (75 mg orally disintegrating tablet).
- Clinical Utility: Extremely effective acute abortive agents that do not cause vasoconstriction; safe in patients with vascular disease or contraindications to triptans.
- 5-HT 1F Receptor Agonist (Lasmiditan):
- Selectively targets the 5-HT 1F receptor without vasoconstrictive activity. Causes central sedation; patients must be advised not to drive or operate machinery for at least 8 hours after ingestion.
- Preventive Pharmacotherapies & Adverse Effect Profiles:
- Topiramate: Causes carbonic anhydrase inhibition. Side effects: weight loss, cognitive slowing / word-finding difficulty ("Dopamax"), paresthesias, metabolic acidosis, nephrolithiasis (calcium phosphate stones), and acute angle-closure glaucoma.
- Divalproex Sodium / Valproic Acid: Causes weight gain, tremor, alopecia, hepatotoxicity, pancreatitis, and severe teratogenicity (neural tube defects, craniofacial defects, cognitive deficits); strictly avoided in women of childbearing potential.
- Amitriptyline: Tricyclic antidepressant. Side effects: sedation, weight gain, xerostomia, urinary retention, constipation, and QTc prolongation.
- CGRP Pathway Monoclonal Antibodies: Erenumab (targets CGRP receptor; risk of severe constipation and hypertension), Galcanezumab, Fremanezumab, Eptinezumab (target CGRP ligand). Administered monthly or quarterly SC/IV; highly effective with minimal systemic organ toxicities.
Secondary Headaches: Red Flags & Idiopathic Intracranial Hypertension
-
"SNOOP4" Red Flag Criteria Mandating Neuroimaging (Brain MRI):
- S — Systemic symptoms (fever, night sweats, weight loss) or systemic illness (known malignancy, HIV/AIDS, immunosuppression).
- N — Neurologic signs or focal deficits (cranial nerve palsies, weakness, sensory loss, altered mental status).
- O — Onset sudden ("thunderclap" headache reaching peak <1 min -> rules out SAH, RCVS, venous sinus thrombosis).
- O — Older age at onset (>50 years -> rules out giant cell / temporal arteritis, intracranial mass lesion).
- P4 — Pattern change or progressive headache; Papilledema on funduscopy; Positional headache (worse supine -> elevated ICP; worse upright -> intracranial hypotension / CSF leak); Precipitated by Valsalva, coughing, or exercise.
-
Idiopathic Intracranial Hypertension (IIH / Pseudotumor Ceredri):
- Demographics: Overweight / obese women of childbearing age (20-45 years). Associated with tetracyclines (doxycycline, minocycline), isotretinoin, excess Vitamin A, and growth hormone.
- Clinical Presentation: Daily generalized headache, transient visual obscurations (brief dimming or loss of vision lasting seconds with postural changes), pulsatile synchronous tinnitus ("whooshing" sound in ears), horizontal diplopia from unilateral or bilateral cranial nerve VI (abducens) palsy, and bilateral papilledema.
- Diagnostic Criteria (Modified Dandy):
- Symptoms and signs of elevated intracranial pressure without focal neurological deficits (except CN VI palsy).
- Brain MRI with MR Venography (MRV): Normal brain parenchyma (rules out space-occupying mass and cerebral venous sinus thrombosis); classic secondary signs include empty sella turcica, flattening of the posterior globe/sclera, and distension of perioptic subarachnoid space.
- Lumbar Puncture: Elevated opening pressure (> 250 mm H2O in adults, >280 in children) with completely normal CSF biochemical, cytological, and microbiological composition.
- Management:
- Weight loss and low-sodium diet (mandatory long-term intervention).
- Acetazolamide (1 to 4 g/day): First-line medical therapy; carbonic anhydrase inhibitor that reduces choroid plexus CSF production.
- Topiramate: Second-line / adjunctive agent (promotes weight loss and weak carbonic anhydrase inhibition).
- Surgical Intervention: Optic nerve sheath fenestration (ONSF) or CSF diversion (ventriculoperitoneal / lumboperitoneal shunt) indicated for medically refractory disease or progressive, permanent visual field loss (monitored by serial automated Humphrey visual field testing).
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