How headache is tested on Step 1

Duration, location, and associated features separate the primary headaches.

HeadachePatternFeaturesTreatment
MigraineUnilateral, pulsating, 4–72 hNausea, photophobia, phonophobia, auraNSAIDs, triptans; prevention with propranolol, topiramate, amitriptyline, CGRP antagonists
ClusterUnilateral orbital, 15–180 min, in clustersTearing, rhinorrhea, ptosis, miosis; restless100% oxygen, triptan; verapamil prevention
Tension-typeBilateral, band-like, 30 min to daysNo nausea or aura; muscle tightnessAnalgesics, NSAIDs
Trigeminal neuralgiaSeconds of electric pain in V2/V3Triggered by chewing, touchCarbamazepine

Medication overuse headache develops with frequent use of acute pain medicines.

Migraine compared with cluster headache

Behavior during the attack is a strong clue.

MigraineMore common in womenHours to daysPulsating; nausea, light sensitivityLies still in a dark roomMay have visual auraClusterMore common in menMinutes to 3 hours, often at nightStabbing pain behind one eyeRestless, pacesIpsilateral tearing, nasal congestionvs
Migraine vs cluster. Migraine aura is a spreading positive symptom (zigzag lines, tingling) that lasts 5–60 minutes.

Pharmacology of migraine

Acute drugs abort attacks; preventive drugs reduce their frequency.

  • Triptans (sumatriptan): 5-HT1B/1D agonists that constrict cranial vessels and block release of neuropeptides; contraindicated in coronary artery disease, Prinzmetal angina, and uncontrolled hypertension.
  • CGRP-targeted drugs: monoclonal antibodies (erenumab, fremanezumab) for prevention; small-molecule gepants (ubrogepant, rimegepant) for acute or preventive use.
  • Prevention: propranolol, topiramate, amitriptyline, or valproate.
  • Antiemetics: metoclopramide and prochlorperazine (dopamine antagonists) relieve nausea and headache.

Red flags for secondary headache

These features demand imaging or urgent testing.

ThunderclapWorst headache of life, sudden → subarachnoidhemorrhage; CT then LPFever, stiff neckMeningitis or encephalitisAge > 50, jaw painGiant cell arteritis; check ESR, start steroids toprotect visionPapilledemaMass or idiopathic intracranial hypertensionNew neuro deficitStroke, tumor, abscess
Red flags. Idiopathic intracranial hypertension classically affects young women with obesity and can be caused by vitamin A or tetracyclines.

Worked example

Choose an acute treatment safely.

functions Worked example — migraine with heart disease

A 58-year-old with stable coronary artery disease has recurrent one-sided throbbing headaches with nausea and light sensitivity. They ask about sumatriptan. Is it appropriate?

  1. The pattern fits migraine without aura.
  2. Sumatriptan activates 5-HT1B receptors, which constrict blood vessels, including coronary arteries.
  3. In coronary artery disease, triptans can provoke ischemia.
  4. Use an NSAID with an antiemetic, or a gepant, which does not constrict vessels.

Answer. No; triptans are contraindicated in coronary artery disease. Use NSAIDs and antiemetics or a CGRP antagonist.