Almost every week someone sits down in my consulting room at Happiness Clinic in Dubai, points to the back of their head and says, “It must be my blood pressure.” Sometimes it is. More often it is a migraine, neck pain from too many hours bent over a laptop, or an irritated nerve. People want to know how to treat a headache; the useful first step is working out which of these it is.

I am Dr Marc Gabrielli, Consultant in Family Medicine at Happiness Clinic. I wrote this with Nicolas Amat, senior physiotherapist at the clinic, because two of these four headaches start in the neck, and that is his territory as much as mine. What follows is roughly the conversation we have in clinic in Dubai: how the pain feels, where it starts, what sets it off, which signs worry me, and how we treat a headache once we know the cause.

Headaches blamed on high blood pressure

This is the one patients mention first, and the one I have to be most honest about. Mild or stable hypertension usually causes no symptoms at all. That is exactly why it goes unnoticed for years. Many people in Dubai buy a home monitor, check it during a headache, see a slightly raised number and conclude the pressure caused the pain. Often it is the other way round: pain, stress and poor sleep push the reading up.

Some patients with high blood pressure do describe a heavy, pressing feeling at the back of the head, sometimes worse in the morning. I take that description seriously, but I do not treat it as proof. Plenty of hypertensive patients never have a headache, and plenty of morning occipital headaches have nothing to do with blood pressure.

What changes everything is the combination of a sudden, severe headache with a very high reading, or with other symptoms. That situation is not a GP appointment. Call 998 if a headache comes with any of these:

• Very high blood pressure readings with a severe or sudden headache
• Blurred or lost vision, or new visual disturbance
• Chest pain or shortness of breath
• Weakness, numbness or difficulty speaking on one side
• Confusion, drowsiness or repeated vomiting

For everything else, the useful step is a proper assessment rather than guessing from one reading. I check blood pressure properly in clinic, look at how you measure at home, and decide whether we are dealing with hypertension, a headache, or both. As an emergency physician by background, I would rather see a worrying headache too early than too late.

Migraine

Migraine has a personality of its own. The pain is often on one side, throbbing or pulsating, and builds over an hour or so. Light and noise become hard to bear, and many people feel sick or vomit. They want a dark, quiet room. Some get an aura beforehand, typically a zigzag or flickering spot in the vision, sometimes tingling, that comes on gradually and fades.

Triggers vary between people, but the usual suspects are irregular sleep, stress or the drop after stress, skipped meals, dehydration, and for many women the menstrual cycle. Long flights, Ramadan fasting hours and summer heat all come up in Dubai consultations.

A family doctor can handle most migraine well: confirming the diagnosis, sorting out what to take during an attack, spotting medication-overuse headache, and discussing prevention when attacks are frequent. My job is also to notice when it is not just migraine. A first ever aura after forty, a headache that has changed character, attacks that never fully clear, or neurological signs that do not fade all deserve further investigation.

A brief aside. There are rare primary headaches called hemicranias, hemicrania continua and paroxysmal hemicrania, that cause strictly one-sided pain, often with a red or watering eye or a blocked nostril on the same side. They respond to a specific prescription medicine, indomethacin, and they are a medical diagnosis. They are neither migraine nor a neck problem, and physiotherapy alone will not settle them.

Occipital neuralgia, the nerve at the back of the head

French-speaking patients often call this Arnold’s neuralgia. In English the term is occipital neuralgia, and it feels nothing like a migraine. Patients describe brief, sharp, shooting or electric shocks that start at the base of the skull, usually on one side, and travel along the greater occipital nerve toward the top of the head, the temple or behind the eye.

The attacks last seconds, sometimes come in bursts, and are often set off by turning the head, looking up, lying on a firm pillow or simply brushing the hair. The scalp over the nerve can be tender or oddly sensitive. Between jolts there may be a background ache.

Diagnosis is clinical, and part of my job is to rule out other causes: an upper cervical problem, shingles in that area, or a structural cause when the examination is not typical. Treatment depends on the cause. Medication aimed at nerve pain is one option. A greater occipital nerve block is sometimes discussed for persistent cases; whether it is suitable, and who performs it, is a decision made after examination.

Nicolas often sees a mechanical contribution here. In his words: “When the upper neck muscles are tight and the joints at the top of the spine move poorly, the nerve has less room. Working on that mechanics does not replace the medical diagnosis, but it often reduces how easily the attacks are triggered.”

Nuchal or cervicogenic headache, the one that starts in the neck

This is the most common pattern in office workers here, and the one patients confuse most with blood pressure. The pain is dull, aching and fairly continuous rather than electric. It starts in the nape or upper neck and climbs up the back of the head, sometimes to the forehead or behind one eye, usually on the same side.

It tends to build through the day, worse after long desk sessions, driving, phone use, or sleeping awkwardly. The neck feels stiff, turning the head is limited, and pressing on certain points at the top of the neck reproduces the headache. Cold air conditioning blowing on the neck is a complaint I hear often.

This is where physiotherapy has a real role. Nicolas has more than twenty years of experience, trained in France, Belgium, Switzerland and Thailand, and has worked full time in Dubai since 2023, mostly on musculoskeletal problems including the neck. He uses manual therapy, dry needling, cupping and taping depending on the patient, together with exercises and practical advice on workstation and sleep position. “The treatment session is only half of it,” he says. “If the screen stays too low and the shoulders stay up all day, the headache comes back.”

My part is making sure it really is the neck. New neck pain with fever, after trauma, with arm weakness or numbness, or in someone with a history of cancer is assessed medically first.

Telling them apart in practice

If I had to compress the consultation into a few lines: the headache truly linked to blood pressure is uncommon and matters when it is severe and comes with other symptoms. Migraine throbs, makes you avoid light and noise and often brings nausea. Occipital neuralgia is a jolt, seconds long, electric, triggered by touch or movement. A cervicogenic headache is a dull ache that starts in a stiff neck and grows with posture.

Many people have more than one. A migraine sufferer can also have a stiff neck, and a hypertensive patient can have tension in the shoulders. That is why we examine rather than label, and why Nicolas and I work in the same building and talk about shared patients.

Any headache described as the worst of your life, reaching full strength within a minute, or arriving with fever and a stiff neck, confusion, fainting, weakness or speech trouble needs 998, not a booking.

Booking a headache assessment

If you want to know how to treat a headache that has changed, keeps coming back, or does not fit a single label, book a consultation at Happiness Clinic with your family doctor, at villa 865A, Jumeirah Street, Umm Suqeim 3, opposite Wild Wadi. Bring your home blood pressure readings and a note of when the headaches happen. If the neck is involved, we can arrange a session with Nicolas Amat. Home visits are possible in Jumeirah and Burj Al Arab.

Call or message Happiness Clinic on +971 56 300 0858. For any emergency, call 998.