From the Guidelines
The initial evaluation of a patient with headache should begin with a thorough history and physical examination to distinguish between primary headaches and secondary headaches caused by underlying conditions. Key elements of the history include assessing headache characteristics (onset, location, quality, severity), associated symptoms, exacerbating/alleviating factors, and red flags such as sudden onset, fever, neurological deficits, or onset after age 50 1. Vital signs, neurological examination, and fundoscopy should be performed.
For primary headaches, initial treatment typically includes:
- NSAIDs such as ibuprofen 400-600mg or naproxen 500mg, or acetaminophen 1000mg 1
- Triptans like sumatriptan 50-100mg orally (or 6mg subcutaneously for severe cases) may be used if NSAIDs are ineffective 1
- Patients should rest in a quiet, dark room and maintain hydration
- Antiemetics such as metoclopramide 10mg or prochlorperazine 10mg can help with associated nausea
For suspected secondary headaches, immediate neuroimaging (CT or MRI) and additional testing based on clinical suspicion are warranted 1. Patients should be educated about headache triggers, lifestyle modifications, and when to seek emergency care (severe sudden headache, altered mental status, or neurological deficits) 1. This approach balances symptomatic relief while ensuring serious underlying causes are not missed.
Some key points to consider in the management of migraine headaches include:
- The use of a headache diary to track symptoms and identify patterns 1
- The importance of individualized treatment plans, taking into account patient preferences and medical history 1
- The potential for medication overuse headaches and the need to monitor patients for this condition 1
From the Research
Initial Evaluation of Headache
The initial evaluation of a patient presenting with a headache involves a detailed history and physical examination to distinguish between primary and secondary headache disorders 2, 3. A thorough history and physical examination can help identify key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache.
History Taking
Taking a thorough and methodical headache history is the mainstay for diagnosis of both primary and secondary headache disorders 4. The history should include questions about the onset, duration, frequency, and characteristics of the headache, as well as any associated symptoms or triggers.
Physical Examination
A targeted physical examination of the patient with headache can help identify specific physical findings, such as papilledema, Horner's syndrome, or cranial nerve palsy, which can direct the evaluation in the proper direction 5. The physical examination should include a complete neurological examination, including evaluation of the patient's mental status, cranial nerves, motor and sensory function, and reflexes.
Red Flags
Certain symptoms or signs, known as red flags, can indicate a secondary headache disorder and warrant immediate evaluation 2, 3. These include:
- Acute thunderclap headache
- Fever
- Meningeal irritation on physical examination
- Papilledema with focal neurologic signs
- Impaired consciousness
- Concern for acute glaucoma
Diagnostic Approach
A systematic framework, such as the SNNOOP10 mnemonic, can help detect life-threatening secondary causes of headaches 2. The diagnostic approach should include consideration of neuroimaging, such as noncontrast computed tomography of the head or magnetic resonance imaging of the brain, and serum or spinal fluid analysis if indicated.
Treatment Approach
The treatment approach for headache depends on the underlying cause and may include acute treatments, such as analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan, as well as preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA 6.