Headaches that won't go away: causes nobody checks

A headache that will not go away is not automatically a brain tumour, but it does deserve a structured check. The most commonly missed causes are medication overuse, chronic migraine, sleep apnoea, eye pressure, jaw or neck drivers, and age-specific red flags such as giant cell arteritis. The right approach is not panic, it is pattern recognition plus clear escalation when the headache is new, severe, changing or linked to neurological or visual symptoms.

First, rule out danger patterns

The first job is to sort persistent headache into two groups: headache that needs urgent medical assessment, and headache that needs a careful non-urgent diagnosis and plan. Most long-running headaches are primary headache disorders such as migraine or tension-type headache. That does not make them minor. It means the diagnosis is based on the pattern, examination and absence of red flags, not on one magic blood test.

Seek urgent help now if the headache is thunderclap, reaches maximum intensity within minutes, follows a head injury, comes with weakness, numbness, confusion, seizure, fainting, fever, neck stiffness, new rash, severe vomiting, new visual loss, eye pain with a red eye, pregnancy or early postpartum status, cancer, immune suppression, or a new headache after age 50. A headache with a painful red eye, misty vision or haloes can be acute narrow-angle glaucoma, which NICE lists as a condition that can mimic headache disorders.¹

For non-urgent persistent headaches, the mistake is often jumping straight to "scan or no scan". NICE advises not referring people with diagnosed tension-type headache, migraine, cluster headache or medication-overuse headache for neuroimaging solely for reassurance.¹ That does not mean scans are never needed. It means the decision should be driven by red flags, examination and an atypical pattern.

Medication overuse

Medication-overuse headache is one of the most common reasons a headache becomes daily. It can happen with paracetamol, aspirin, NSAIDs, triptans, opioids and combination painkillers. The trap is that every dose makes sense on the day, but the overall pattern keeps the nervous system sensitised.

The International Classification of Headache Disorders describes medication-overuse headache as headache on 15 or more days a month in someone with a pre-existing headache disorder, plus regular overuse of acute headache medicines for more than 3 months.² The threshold is usually 10 or more days a month for triptans, opioids, ergotamine or combination analgesics, and 15 or more days a month for simple analgesics such as paracetamol or NSAIDs.²

BASH also warns that painkillers taken for other pain, such as back or joint pain, can worsen an underlying migraine or tension-type headache pattern.³ That is why a headache diary must record all pain relief days, not just "headache tablets".

NICE recommends explaining that medication-overuse headache is treated by withdrawing overused acute medication, with close support because symptoms may worsen before they improve.¹ Do this with medical guidance if you use opioids, codeine, sedatives, have complex disease, are pregnant, or have previously failed withdrawal.

Migraine that has become daily

Many people think migraine means a dramatic one-sided headache with vomiting and flashing lights. In real life, migraine can be pressure-like, bilateral, neck-heavy, sinus-like, hormonal, vestibular, visual, or mostly expressed as light sensitivity and cognitive shutdown. Chronic migraine is defined by NICE as headache on 15 or more days per month for more than 3 months, with at least 8 days having migraine features.¹

This matters because chronic migraine is often undertreated. People keep using acute medicines without a preventive plan, then develop medication overuse, then get told the problem is anxiety, screens or posture. NICE includes several preventive options and says migraine preventive treatment should be reviewed 3 to 6 months after starting.¹

"Sinus headache" is another common wrong turn. A systematic review found that most people presenting with self-diagnosed or physician-diagnosed sinus headache actually had migraine or another primary headache disorder, not a sinus cause.¹⁰ Nasal congestion can occur during migraine. True sinus-related headache is more convincing when there is purulent nasal discharge, fever, acute infection features, facial tenderness and worsening with a clear sinus illness.

Sleep, pressure, eyes, jaw and neck

Sleep apnoea is under-checked because people often do not know they stop breathing at night. NICE recommends taking a sleep history and assessing for obstructive sleep apnoea-hypopnoea syndrome if someone has two or more features such as snoring, witnessed apnoeas, unrefreshing sleep, waking headaches, unexplained sleepiness, nocturia, choking during sleep, insomnia or cognitive dysfunction.⁴ The NHS also lists waking with a headache among daytime symptoms of sleep apnoea.⁵

Raised pressure inside the skull is less common but important. Idiopathic intracranial hypertension can cause headache, transient visual obscurations, pulsatile tinnitus, visual blurring, double vision and papilloedema. Consensus guidelines emphasise three aims: treat the underlying disease, protect vision and reduce headache morbidity.⁷ This is one reason an eye examination can matter in persistent headache, especially if there are visual symptoms.

Jaw and neck drivers can also be real. Teeth grinding, temporomandibular joint problems, neck stiffness, poor sleep and sustained desk posture can all feed head pain, but they should not become a lazy explanation for a new neurological pattern. If the headache changes with chewing, jaw opening, neck movement, sleep position or morning jaw soreness, that is useful information for your GP, dentist, physiotherapist or headache clinic.

Blood pressure is worth measuring, but ordinary hypertension is often silent and should not be blamed for every daily headache. The exception is a very high reading with severe headache, chest pain, breathlessness, confusion, weakness, visual change or pregnancy-related symptoms, which needs urgent assessment.

The headache that started one day and stayed

New daily persistent headache is a specific pattern: the person remembers a distinct onset, and the pain becomes continuous and unremitting within 24 hours.⁸ It is different from migraine gradually becoming more frequent over months or years.

A 2023 systematic review and meta-analysis found 46 studies with 2,155 patients and reported that about 67% of new daily persistent headache cases had a chronic migraine phenotype.⁹ The same review concluded that high-quality evidence is lacking and that the condition remains a distinct, recognisable disorder.⁹

The clinical point is not to self-label. It is to tell the story accurately: "I can name the day this began, and it has not stopped." That sentence should prompt a different line of questioning, including infection, head injury, cerebrospinal fluid pressure problems, venous sinus thrombosis, inflammatory disease and other secondary causes before settling on a primary headache diagnosis.

How to get a better GP review

Go in with data. Record headache days, migraine-feature days, medicine days, sleep quality, waking headaches, menstrual timing, alcohol, caffeine, hydration, neck or jaw triggers, visual symptoms and blood pressure readings if available. Use Start Here to organise the timeline, the health library to understand the main diagnoses, and insights to sense-check claims about supplements, posture or hidden inflammation. If you are trialling supplements or preventives, track one change at a time with the stack builder.

Ask for a diagnosis, not just a painkiller. The answer may be chronic migraine, tension-type headache, medication overuse, cluster headache, sleep apnoea, IIH, GCA, sinus disease, eye disease, jaw dysfunction, post-traumatic headache or something rarer. A clear working diagnosis is what turns persistent headache from a blur into a plan.

A headache that will not go away needs a better question than "is this serious or not?" The better question is: what pattern is this, what dangerous mimics have been ruled out, and what modifiable driver has not yet been checked?

This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.