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This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
Key points
- First separate primary headache (migraine, tension-type, cluster) from secondary headache using red flags: thunderclap onset, fever/meningism, focal neurological deficit, papilloedema, cancer/immunosuppression, pregnancy/postpartum, age >50 with new headache, and trauma
- Thunderclap headache is subarachnoid haemorrhage until proven otherwise: urgent non-contrast CT head; if CT negative and suspicion remains, lumbar puncture or CTA depending on timing and local pathway
- Do not label a first or worst headache as migraine until secondary causes have been considered; migraine is recurrent, stereotyped and often associated with nausea, photophobia and functional impairment
- Medication-overuse headache is common in chronic daily headache and is driven by frequent use of triptans, opioids, combination analgesics or simple analgesics
- Management is presentation-based: stabilize unstable patients, investigate red flags urgently, treat primary headaches with evidence-based acute and preventive therapy, and give safety-netting
Approach to the Presentation
Headache is a classic MCCQE1 presentation because it rewards a disciplined clinical approach rather than memorisation of headache labels. Start with ABCs and vital signs if the patient is acutely unwell, then characterize onset, time to peak, severity, pattern, previous similar headaches, neurological symptoms, systemic symptoms, pregnancy or postpartum status, anticoagulant use, malignancy, immunosuppression, trauma and medication exposure. The key fork is not migraine versus tension headache; it is dangerous secondary headache versus primary headache. Once secondary headache is unlikely, phenotype the primary headache, assess disability and medication overuse, and provide a clear acute and preventive plan.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Subarachnoid haemorrhage | must-not-miss | Thunderclap headache maximal within seconds to minutes, exertional or sexual trigger, neck stiffness, vomiting, collapse, reduced consciousness; may have normal neurological examination | Urgent non-contrast CT head; if negative and suspicion persists, LP for xanthochromia/RBCs or CTA according to timing and local pathway |
| Meningitis / encephalitis | must-not-miss | Fever, headache, photophobia, neck stiffness, rash, altered mental status, seizures; immunocompromised patients may be subtle | Blood cultures, CBC, CRP, CT before LP if indicated, CSF cell count/glucose/protein/culture/PCR |
| Intracranial mass / raised intracranial pressure | must-not-miss | Progressive morning headache, vomiting, papilloedema, worse with Valsalva or lying flat, focal deficits, seizure, cancer history | MRI brain with contrast preferred; CT head if urgent or MRI unavailable |
| Giant cell arteritis | must-not-miss | Age >50, new temporal headache, scalp tenderness, jaw claudication, visual symptoms, polymyalgia rheumatica symptoms | ESR/CRP, platelets, temporal artery ultrasound/biopsy; treat immediately with high-dose glucocorticoids if suspected |
| Cerebral venous sinus thrombosis | must-not-miss | Headache in pregnancy/postpartum, OCP use, thrombophilia, malignancy; may have papilloedema, seizure, focal signs or subacute progressive course | CT venography or MR venography |
| Migraine with or without aura | common | Recurrent unilateral or bilateral pulsating headache, moderate-severe, nausea, photophobia/phonophobia, worse with activity; aura evolves over minutes and resolves <60 min | Clinical diagnosis after red flags excluded; headache diary helps confirm pattern |
| Tension-type headache | common | Bilateral pressing/tight band-like pain, mild-moderate, not worsened by routine activity, minimal nausea and no prominent photophobia | Clinical diagnosis; normal neurological examination |
| Medication-overuse headache | common | Headache on >=15 days/month with regular overuse of acute medication; often daily, refractory and worst on waking | Medication history: triptans/opioids/combination analgesics >=10 days/month or simple analgesics >=15 days/month |
| Sinusitis / dental / temporomandibular cause | common | Facial pressure, purulent nasal discharge, dental pain, fever, worse leaning forward; usually not isolated severe headache | Clinical; imaging only if complicated or recurrent |
| Cluster headache / trigeminal autonomic cephalalgia | less common | Severe unilateral orbital/temporal pain lasting 15-180 min with ipsilateral lacrimation, conjunctival injection, rhinorrhoea, ptosis or restlessness | Clinical; MRI if atypical or first presentation |
| Idiopathic intracranial hypertension | less common | Young woman, obesity, headache, transient visual obscurations, pulsatile tinnitus, diplopia from VI palsy, papilloedema | MRI/MRV then LP opening pressure with normal CSF composition |
Red Flags & Key History
Symptoms
Thunderclap onset or 'worst headache of life'
Fever, neck stiffness, photophobia, rash or altered mental status
New focal neurological symptoms, seizure, papilloedema or persistent vomiting
New headache after age 50, especially with jaw claudication or scalp tenderness
Pregnancy/postpartum, anticoagulation, cancer, HIV/immunosuppression or recent head trauma
Recurrent stereotyped headache with nausea and photophobia
Daily analgesic or triptan use
Signs
Papilloedema or sixth nerve palsy
Reduced GCS or meningism
Temporal artery tenderness, reduced pulse or visual symptoms
Focal motor, sensory, speech or cerebellar deficit
Normal neurological examination between recurrent stereotyped attacks
Approach to Investigation
First-line
Focused neurological examination + vital signsDocument GCS, fever, BP, meningism, fundoscopy/papilloedema, cranial nerves, motor/sensory/cerebellar signs and gait.
Non-contrast CT head when red flags are presentFirst-line for thunderclap headache, trauma, reduced consciousness, focal deficit or suspected haemorrhage.
CBC, electrolytes, creatinine, glucose, ESR/CRP where indicatedESR/CRP and platelets are essential when giant cell arteritis is possible; glucose/electrolytes identify mimics and contributors.
Pregnancy test in people of reproductive potentialChanges imaging, medication choice and differential: pre-eclampsia, CVST, pituitary apoplexy.
Second-line
Lumbar punctureIf meningitis/encephalitis suspected, or if subarachnoid haemorrhage remains possible after negative CT depending on timing and local protocol. Measure opening pressure when raised ICP/IIH suspected.
CTA/CTV/MRVCTA for aneurysm/dissection; CTV/MRV for cerebral venous sinus thrombosis.
MRI brainPreferred for mass lesion, posterior fossa pathology, chronic progressive headache or atypical headache syndromes.
Specialist
Neurology referralThunderclap headache with negative initial tests, refractory migraine, diagnostic uncertainty, abnormal imaging or progressive neurological symptoms.
Ophthalmology / rheumatologyUrgent for suspected giant cell arteritis with visual symptoms or papilloedema.
Management Principles
Canadian Headache Society guidance + MCC Headache objective1
Immediate stabilization
- ABCs, IV access and monitoring if reduced consciousness, sepsis, seizure or severe hypertension
- Treat suspected meningitis/encephalitis promptly after cultures; do not delay antibiotics for imaging if unstable
- Treat suspected giant cell arteritis immediately with high-dose glucocorticoids when visual symptoms or strong clinical suspicion are present
2
Acute migraine
- NSAID such as naproxen or ibuprofen if no contraindication
- Triptan for moderate-severe migraine or NSAID failure; avoid in vascular disease and hemiplegic/basilar-type presentations
- ED severe migraine: antiemetic dopamine antagonist such as metoclopramide or prochlorperazine plus fluids if dehydrated; avoid opioids where possible
3
Prevention and chronic headache
- Identify triggers, sleep disruption, caffeine, mood disorder and medication overuse
- Consider preventive therapy when attacks are frequent, disabling or acute medication use is escalating: propranolol, amitriptyline, topiramate, candesartan or CGRP-pathway therapy depending on context
- Withdraw overused acute medications with a structured plan and bridge therapy where appropriate
4
Safety-netting
- Return urgently for sudden worst headache, fever/neck stiffness, persistent vomiting, new neurological deficit, visual loss, confusion, seizure or a clearly different headache pattern
Complications & Pitfalls
- Calling thunderclap migraine: migraine should not be the first diagnosis when pain peaks instantly.
- Forgetting giant cell arteritis: new headache after age 50 with jaw claudication or visual symptoms needs immediate steroids, not outpatient observation.
- Overusing CT: chronic recurrent stable headache with normal exam usually does not need imaging; red flags change this.
- Missing medication overuse: escalating triptan, opioid or combination analgesic use perpetuates headache.
- Unsafe triptan prescribing: avoid triptans in significant vascular disease and atypical aura with motor/brainstem features unless specialist guidance supports use.
MCCQE1 Exam Tips
- 1MCC headache questions usually ask whether you recognize the red flag before naming the primary headache syndrome.
- 2Thunderclap headache: CT first. If CT is negative but suspicion remains, LP or vascular imaging is the next step depending on timing and pathway.
- 3Age >50 + new headache + jaw claudication = giant cell arteritis; start steroids before confirmatory biopsy if suspicion is high.
- 4Migraine aura is positive neurological symptoms evolving over minutes; TIA is usually sudden negative symptoms. Do not confuse the two when vascular risk is high.
- 5Medication-overuse headache is tested by the history of frequent analgesic/triptan use, not by imaging.
- 6Opioids are poor migraine care in most exam scenarios; use NSAIDs, triptans, antiemetics and prevention instead.
- 7Always document a neurological examination and fundoscopy in red-flag headache.
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