0 hours
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
0.5 hours
These are activities that require reflection on feedback about your work.
0 hours
These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
recent years, following some simple steps can help you confidently distinguish migraine from other conditions that could underlie the symptoms.
The first step involves determining whether headaches are primary (i.e. not caused by underlying pathology) or secondary (i.e. caused by a structural or other objectively defined organic issue), says Richard Stark, neurologist at the Alfred Hospital and Adjunct Clinical Professor in the Department of Neuroscience at Monash University.
To identify possible causes for secondary headaches, he recommends using the SNOOP mnemonic:
“The good thing about the SNOOP acronym is that it not only reminds you of the things that you should be thinking about, but it actually gives you an idea of how you should be investigating them as well,” Professor Stark says.
For example, systemic features might prompt assessment of inflammatory markers, papilloedema suggests the need for scans, while a thunderclap headache raises suspicion of subarachnoid haemorrhage—necessitating urgent assessment.
However, most patients don’t have a secondary headache disorder, he says.
“If a patient has had a long history of recurrent headaches that have the same pattern, it’s very likely that it’s going to be a primary headache disorder.”
While the International Headache Society has detailed diagnostic criteria for migraine, the validated ID Migraine tool offers a simple way to identify migraine in day-to-day practice, Professor Stark says.
It involves asking three questions:
“If you say yes to two out of three of those questions, it’s very likely that it’s migraine.”
While cervicogenic headaches do occur in isolation, Professor Stark cautions against assuming that neck pain excludes migraine.
Migraines have various triggers, and one of the strongest is other head or neck pain, he explains.
“So we often get people who have a bit of a susceptibility for migraine and might have had a few migraines earlier in life. They get a whiplash injury, and they get some neck pain. And you go through the history, and they’ve got elements of neck pain, but they’ve also got elements of migraine. They get nausea with it, they get light sensitivity, it’s a bit episodic. And it’s hard to work out what’s going on.”
“The answer is that they’ve got both. So they’ve got migraine, and they’ve got cervicogenic involvement.”
The same principle applies in other situations, such as headaches after a minor head injury in people with a migraine history.
It’s important to recognise this overlap because migraine-specific therapies may still offer substantial benefit, even when other mechanisms are at play.
While both conditions can be episodic, cluster headaches have a distinct presentation, Professor Stark stresses.
“If you take the history properly, in the majority of these cases, you can separate clearly into one or the other.”
Patients with cluster headache will report one to three attacks every one to two days during an episode. Each attack usually lasts between 20 and 90 minutes before resolving.
“And these attacks keep on going typically for about six weeks. And then they might have a period of a year where they have no headache at all.”
The pain is excruciating, strictly unilateral and usually centred around the eye.
“It’s like having a red-hot poker put in your eye. People sometimes use the term suicide headache because it’s so bad that they really don’t want to live when they’ve got it.”
It’s often accompanied by autonomic symptoms like eye redness, tearing, and rhinorrhoea on the affected side.
Patients also tend to respond differently to the symptoms, he adds.
“Patients with migraine want to go and rest. Patients with cluster headache want to pace around and move their head and bang their head.”
Orthostatic headaches signify altered intracranial pressure and present differently whether it’s raised or lowered, Professor Stark notes.
Low pressure headaches are typically worse in standing.
“And sometimes that’s very obvious. For example, they’ve had an epidural and they get a headache afterwards, which is worse standing up. And they’ve obviously had a dural puncture. But we sometimes see people who get spontaneous low-pressure headaches where they develop a CSF leak in the spinal cord. And that can be quite difficult to diagnose and treat,” he says.
“By contrast, people who’ve got high pressure headaches—who are developing hydrocephalus or have a brain tumour or something of that sort—are often worse when they’re lying down. And you really need to be looking at imaging and making sure there are no signs of raised intracranial pressure.”
Blockage of CSF flow at the foramen magnum, sometimes caused by significant descent of the cerebellar tonsils associated with a Chiari malformation, can result in a headache with coughing or Valsalva manoeuvre, he adds.
“It’s pretty rare, but it’s a specific sort of headache for which there is specific treatment.”
Chronic headaches are defined as occurring on more than 15 days per month, and chronic migraine (previously known as transformed migraine) is one of the most common types, Professor Stark says.
“Most patients with chronic migraine start off with episodic migraine.”
Central sensitisation or medication overuse can cause them to progress, he explains.
Chronic migraine can be difficult to identify because classic features like nausea and light sensitivity tend to become less obvious.
Diagnosis therefore hinges on exploring the symptom history, he says.
Differentials include chronic tension-type headache, which is relatively rare, and new daily persistent headache, which is more common.
“And that’s a situation where someone will come in and say, I’ve really never been prone to headaches much, but I got a headache on the 3rd of November 2025, and it’s been there ever since.”
Migraine sufferers can sometimes develop medication overuse headache if they take pain relievers too frequently—more than 10 days per month for triptans and codeine or 15 days per month for simple analgesics, Professor Stark explains. It’s therefore essential to ask patients about their medication use and address it if needed. Codeine overuse is less common since it was removed from over the counter products, but often requires specialist input to manage, he says. Overuse of triptans and simple analgesics can often be dealt with in GP.
Symptoms like visual disturbance and paraesthesia may raise concerns about transient ischaemic attack (TIA), seizure or structural neurological disease, but their time course is typically different in migraine, Professor Stark explains.
“The key to diagnosis of aura symptoms is that they spread gradually.”
While we once thought migraine auras were caused by vasoconstriction, we now know they result from cortical spreading depression—a wave of altered chemical activity that spreads slowly across the cortex, he explains.
Changes in blood flow follow, he adds.
“Brain autoregulation is such that the blood flow is commensurate to the amount of activity that it’s using. So when you turn off an area of brain, the blood flow to it drops. And that’s basically what’s happening with this.”
The occipital cortex is affected most often, producing visual symptoms such as scintillating scotomas or zig-zag patterns.
These symptoms usually develop and spread over 5 to 20 minutes, helping distinguish migraine aura from mimics. “If it’s a TIA, it’s likely to come on virtually instantly without much in the way of spread,” Professor Stark explains. Similarly, focal seizures can spread through affected areas of the brain, but usually over seconds to a minute.
The same principle applies to sensory aura. Numbness or tingling that slowly progresses up the hand and arm over 20 minutes is more suggestive of migraine aura, whereas abrupt onset of symptoms should raise suspicion of alternative diagnoses, he says.
He recommends a higher level of caution in presentations, atypical symptoms or aura involving the limbs.
“I have a low threshold for doing it. If there’s any suggestion that there is anything atypical, it clears the air,” Professor Stark says.
He advises that imaging is warranted for:
He also recommends imaging if symptoms change, stressing that migraine is common and does not preclude other issues.
“So if patients present with a new or different pattern of symptoms, it’s a mistake to automatically ascribe it to migraine.”
While Medicare rebates are only available for MRI referrals from GPs in certain circumstances, it’s the preferable imaging modality, he adds.
“If you do a CT, you’re probably subjecting the patient to some radiation and you’re not going to answer the questions that are most relevant. I think if you’re going to do some imaging, you ought to do it properly and get an MRI scan.”
Referral is appropriate if you suspect a secondary headache that warrants input from a neurologist or other specialist.
It should also be considered in patients with difficult medication overuse, and in those with chronic migraine, where a neurologist needs to be involved to access PBS-subsidised injectable preventive therapies.
It’s also reasonable to refer patients with cluster headache, which can be complex to manage.
Based on this educational activity, complete these learning modules to gain additional CPD.
Listen to expert interviews.
Click to open in a new tab
Browse the latest articles from Healthed.
Once you confirm you’ve read this article you can complete a Patient Case Review to earn 0.5 hours CPD in the Reviewing Performance (RP) category.
Select ‘Confirm & learn‘ when you have read this article in its entirety and you will be taken to begin your Patient Case Review.
