Headache, facial pain and vertigo

Headache assessment

Ask whether the headache is new, different from usual, sudden at maximum severity, progressive or linked to posture, exertion or pregnancy. Fever, meningism, immunosuppression, cancer, papilloedema, focal deficits, altered consciousness and recent injury raise secondary causes. A headache first appearing after age fifty deserves particular attention to giant cell arteritis and structural disease. Measure observations and perform neurological, visual and funduscopic assessment where feasible. Describe the onset precisely: a patient saying “the worst headache” is less informative than a sudden peak within seconds during exertion.

Thunderclap headache requires urgent evaluation for subarachnoid haemorrhage and other vascular causes such as dissection or reversible cerebral vasoconstriction syndrome. Non-contrast CT is the initial investigation in many acute pathways. Its ability to exclude haemorrhage depends on timing, scanner quality and interpretation. After a negative CT, further investigation such as LP or vascular imaging follows the local pathway and specialist assessment; a normal late scan should not become blanket reassurance. Suspected meningitis or encephalitis needs urgent antimicrobials when indicated without waiting for an unsafe or delayed LP.

Common recurrent syndromes

Migraine commonly produces episodic moderate-to-severe headache with nausea, light/sound sensitivity and activity limitation. Aura usually evolves over minutes, often with positive visual or sensory symptoms; a first atypical episode still requires assessment for vascular disease. Offer appropriate simple analgesia or a triptan when suitable, avoiding contraindications and excessive acute-medication use. Review prevention when attacks are frequent or disabling. Pregnancy, vascular disease and drug interactions change choices. A patient's usual diagnosis does not explain every future headache automatically.

Tension-type headache is usually bilateral and pressure-like without prominent neurological features. Cluster headache causes severe unilateral orbital pain with ipsilateral autonomic features and restlessness; acute oxygen and suitable triptan treatment plus specialist prevention distinguish it from migraine. Brief electric facial pains triggered by touch or chewing suggest trigeminal neuralgia, but sensory loss or atypical findings warrant investigation. Dental disease, sinus disease and temporomandibular problems are alternative facial-pain causes. Medication-overuse headache requires a supported withdrawal and prevention plan, rather than progressively escalating analgesics.

Dizziness is a symptom description

Clarify whether “dizzy” means spinning, impending faint, imbalance or a vague altered sensation. Ask duration, triggers, hearing symptoms, palpitations, headache and neurological symptoms. Check hydration, medication effects, lying/standing pressure where safe, ECG when relevant and glucose. A dizzy patient can have arrhythmia, bleeding or metabolic illness rather than an inner-ear disorder. Acute inability to stand, new diplopia, dysarthria, focal weakness or severe headache requires urgent central-cause assessment, even when nausea dominates the story.

Brief position-triggered vertigo suggests benign paroxysmal positional vertigo. A suitably performed positional test can reproduce typical nystagmus; canal-repositioning manoeuvres treat the mechanical cause. Screen for cervical limitations and use an appropriate technique. Continuous acute vertigo with spontaneous nystagmus is a different syndrome: vestibular neuritis and posterior stroke are important possibilities. The HINTS examination is intended for a defined acute vestibular syndrome and trained examiners, not all episodic dizziness. An incorrectly applied “normal HINTS” cannot safely rule out stroke.

Ménière-type disease combines recurrent vertigo with fluctuating sensorineural hearing symptoms, tinnitus or fullness; arrange audiology/ENT assessment rather than diagnosing it from dizziness alone. New hearing loss with acute vertigo can also accompany vascular disease. Vestibular suppressants may help briefly during severe symptoms but prolonged use can impair compensation and increase falls. Encourage suitable vestibular rehabilitation after the diagnosis is established. Explain that a negative routine head CT is relatively insensitive to some posterior fossa infarcts and does not settle every acute vestibular presentation.

Applying red flags and follow-up

Consider a seventy-year-old with new temporal headache, jaw fatigue and transient visual blurring. Arrange immediate GCA treatment and urgent specialist assessment; a normal ESR would not safely exclude it. Compare a young adult with years of stereotyped migraine, normal examination and no new red flags: management can focus on acute therapy, prevention and a diary, with review for treatment failure. The decision is based on the current presentation rather than age alone or the intensity adjective used.

For a person with brief spinning whenever turning in bed, assess the positional pattern and examine before considering repositioning. A person with continuous vertigo, inability to walk and a new visual-field symptom needs emergency stroke assessment. Provide explicit return instructions for new neurological signs, collapse, fever, worsening headache or persistent vomiting. Check occupational and driving safety, and involve carers when falls or cognitive concerns impair a reliable follow-up plan. Avoid repeated imaging merely to manage anxiety when appropriate assessment supports a benign recurrent syndrome; explain the diagnosis and the circumstances that would change it.

NSW ENT emergency criteria and Australian stroke guidance.

Review checkpoints

• Sudden maximal headache requires urgent assessment for subarachnoid haemorrhage and other vascular causes.
• HINTS is appropriate only for the relevant continuous acute vestibular syndrome and trained examination.
• New focal deficits or severe gait impairment warrant urgent neurological assessment.