Neobook — clinical reference

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Click here to access the Adult Hospital Level Chapter 14: Neurological Disorders with Supporting NEMLC Report-2020-4-Review-Version-3.0-22-November-2025

Migraine

Cluster headache

Trigeminal neuralgia

Tension headache

Medication overuse headache

Idiopathic intracranial hypertension (pseudotumour celebri)

MIGRAINE

G43.0-3/G43.8-9

DESCRIPTION

A migraine is an episodic headache, usually located unilaterally and throbbing/ pulsating in nature, which may occur with or without an aura.
Migraines are usually accompanied by nausea and/or vomiting, photophobia (sensitivity to light) and phonophobia (sensitivity to noise).
There are several variants of migraine.

GENERAL MEASURES

Reassure patient that this is a benign condition.
Attempt to identify any precipitating factors or food triggers from the patient's history.

MEDICINE TREATMENT

Acute treatment

Initiate therapy during the migraine attack or at the onset of the headache.

Analgesia:

Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
- Maximum dose: 15 mg/kg/dose.

NSAID, e.g.:
- Ibuprofen, oral, 400 mg immediately then 8 hourly with meals, if needed.

For nausea:

Metoclopramide, oral/IM, 10 mg 8 hourly, as required.

Prophylaxis (Z29.2)

Regular, daily, prophylactic therapy is advised if:

attacks are frequent, i.e. more than 2–3 per month, or
severe, causing a significant amount of disability, or
attacks are long lasting, or
patient poorly tolerates therapy for acute attacks.

LoE:IIIa^xlvi

Amitriptyline, oral, 10–25 mg at bedtime.
- Up-titrate dose to adequate clinical response.
- Doses greater than 75 mg are seldom required.

LoE:IIb^xlvii

Poor response or contraindication to amitriptyline:

β-blocker, e.g.:
- Propranolol, oral, 40 mg 12 hourly.
  - Titrate dose to adequate response.
  - Maximum dose 120-240 mg daily.

LoE:IIIb^xlviii

REFERRAL

Inadequate response to treatment.

CLUSTER HEADACHE

G44.0

DESCRIPTION

Repetitive episodes of excruciating headache typically of short duration (up to 2 hours) in clusters for weeks to months at a time.
Typically, the headache is of sudden onset, unilateral during the specific cluster, and quickly reaches a climax.
Associated redness of the eye with lacrimation and rhinorrhoea occurs.

MEDICINE TREATMENT

Oxygen inhalation may abort some episodes.

LoE:IIIb^xlix

Analgesics are ineffective.

To induce rapid remission in patients with episodic cluster headache:

Corticosteroids (intermediate-acting) e.g.:
Prednisone, oral, 40 mg daily for 5–10 days.
- Tapering is not necessary when the above duration is used.

LoE:IVb^l

Prophylaxis

Verapamil, oral, 40-80 mg 12 hourly.

REFERRAL

Inadequate response to treatment.

TRIGEMINAL NEURALGIA

G50.0

See: Management of neuropathic pain.

TENSION HEADACHE

G44.2

DESCRIPTION

Tension headaches are described as a tight band around the head and are generally worse in the afternoon.
Usually occurs over the back of the head, but may extend over the entire head.

GENERAL MEASURES

Consider use of relaxation techniques.
Exclude medication overuse headache (see: Medication overuse headache).

MEDICINE TREATMENT

Amitriptyline, oral, 10–75 mg at night.

REFERRAL

Atypical pain and/or focal neurological signs and symptoms suggestive of alternate diagnosis.
Poor response to therapy.

MEDICATION OVERUSE HEADACHE

G44.4

DESCRIPTION

Medication overuse headache generally occurs for ≥ 15 days per month for more than 3 months, and develops as a consequence of regular overuse of analgesics for acute pain-relief.
The headache develops or markedly worsens during medication overuse, and usually, but not invariably, resolves after the overuse is stopped.

LoE:IVb^li

GENERAL MEASURES

Stop all analgesics.
Counsel patient regarding the link between overuse of analgesics and the development of and/or worsening of the headache symptom.
The headache usually resolves after the overuse is stopped, but may transiently worsen.

MEDICINE TREATMENT

Amitriptyline, oral, 10 mg at night.
- Increase to a maximum of 75 mg at night.
  LoE:IIIb^lii
- May be used during withdrawal of acute or symptomatic headache treatment.

IDIOPATHIC INTRACRANIAL HYPERTENSION (PSEUDOTUMOUR CEREBRI)

G93.2

DESCRIPTION

Patients present with symptoms (chronic headache, visual disturbance or loss due to papilloedema and tinnitus) and signs (papilloedema) of raised intracranial pressure without structural intracranial abnormality and with normal CSF composition.

Diagnosis

All patients should have neuro-imaging (CT scan).

If this is normal, i.e. the absence of structural lesions or hydrocephalus, perform a lumbar puncture and measure intracranial pressure.
Diagnosis is confirmed by the presence of raised CSF pressure > 20 cm H₂0.

GENERAL MEASURES

Stop medicines associated with benign intracranial hypertension (e.g. doxycycline, corticosteroids, combined oral contraceptives).
Regular monitoring of visual fields is crucial.
Weight loss.
Repeated lumbar punctures with measurement of opening pressure (do lumbar puncture with patient in left lateral position).
Consider surgery if there is progression of visual defects, despite medical therapy, visual loss at onset or severe papilloedema.

MEDICINE TREATMENT

Discuss all cases with a specialist.

For visual involvement, persistent headaches, or severe papilloedema:

Acetazolamide, oral, 250 mg 12 hourly
- Increase, as required, by 250 mg daily every week to the maximum tolerated dose (not exceeding 4 g daily).

LoE:IIIb^liii

Furosemide, oral, 40 mg daily.

REFERRAL

For neuro-imaging, if not available locally.
Visual symptoms or deterioration of visual fields for ophthalmology evaluation.
Patients not responding to therapy or in need of surgical management.

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-4_Version 2.0_6 June 2025

Chapter 14 Neurological Disorders_14.7 Headache and Facial Pain Syndromes

Headache and Facial Pain Syndromes

Drugs mentioned

ICD-10 codes