Headache, Migraine, and Neurological Red Flags: OPD Clinical Guide for Indian Doctors

Headache is one of the three most common complaints in Indian OPD. Most are benign — but missing a secondary headache (subarachnoid haemorrhage, meningitis, space-occupying lesion) is among the most consequential diagnostic errors in medicine. This guide gives you a structured approach to headache triage, migraine management, and neurological emergency recognition.

Approach to Headache in OPD

The history tells you 90% of what you need. Ask three structured questions before anything else:

Neurological Red Flags: Never Miss These

Any SNOOPPP positive: do not send home with analgesics. Order CT brain (or LP if CT normal and SAH suspected) and refer appropriately.

Migraine: Diagnosis and Acute Treatment

Diagnostic Criteria (ICHD-3)

Migraine without aura: at least 5 attacks, each lasting 4–72 hours, with at least 2 of: unilateral, pulsating, moderate/severe, worse with activity — AND at least 1 of: nausea/vomiting, or photophobia + phonophobia.

The POUND mnemonic is useful in OPD:

• Pulsatile quality
• One-day duration (4–72 hours)
• Unilateral
• Nausea or vomiting
• Disabling severity

4/5 = 92% probability of migraine. 3/5 = 64% probability.

Acute Migraine Treatment (Stepwise)

Migraine Prophylaxis

Offer prophylaxis when: ≥4 migraine days/month, or attacks significantly impair function despite good acute treatment, or frequent triptan use.

First-line options:

• Propranolol 40–160mg OD — avoid in asthma, depression, bradycardia
• Amitriptyline 10–75mg nocte — especially useful if comorbid sleep disorder or tension-type overlap
• Topiramate 25–100mg OD — effective but cognitive side effects (word-finding difficulty) common; start at 25mg and titrate slowly
• Sodium valproate 500–1500mg/day — effective but avoid in women of childbearing age

Trial prophylaxis for minimum 3 months before declaring failure. Target: ≥50% reduction in headache days.

Tension-Type Headache

Most common headache type. Bilateral, pressure/tightening quality, mild-moderate severity, no nausea, not aggravated by routine activity. Often triggered by stress, poor posture, screen time.

Treatment: Paracetamol 1g or Ibuprofen 400mg for acute attacks. For chronic tension headache (≥15 days/month): Amitriptyline 10–25mg nocte is first-line prophylaxis. Physiotherapy, stress management, and screen hygiene advice are equally important.

Stroke Recognition in OPD

Many strokes present first to a GP or clinic doctor. The FAST test in 10 seconds:

• Face drooping — ask to smile
• Arm weakness — raise both arms, watch for drift
• Speech difficulty — repeat a simple phrase
• Time to call 108 — do it immediately if any positive

Vertigo: BPPV vs Central Causes

BPPV (Benign Paroxysmal Positional Vertigo) is the most common cause — brief episodes (<1 min) triggered by head position change, no hearing loss, no neurological signs. Diagnose with Dix-Hallpike test. Treat with Epley manoeuvre (85% resolution in one session).

Red flags suggesting central cause (cerebellar/brainstem pathology — refer to neurology):

• Continuous vertigo lasting days
• New severe headache with vertigo
• Any focal neurological sign (diplopia, dysphagia, ataxia)
• Vertigo + unilateral hearing loss (consider acoustic neuroma)
• Falls with inability to stand still

Seizures in OPD

A first seizure in an adult requires CT brain + EEG before starting antiepileptics. Do not start treatment based on history alone — the diagnosis must be confirmed.

Known epilepsy patient presenting with breakthrough seizure: Check medication adherence, check for fever/illness as trigger, check serum drug levels if available. Do not automatically escalate medication — first address trigger.

Status epilepticus in clinic: Lorazepam 0.1 mg/kg IV or Midazolam 10mg IM (buccal midazolam 10mg if no IV access) → call 108 → second dose at 5 minutes if not terminated → prepare for intubation if third line needed.

Track neurological patients' symptom trends, medication changes, and follow-up intervals systematically. See how CliniqFlo's EMR handles neurology OPD follow-up →