How should I evaluate and manage an adult presenting with a headache without red-flag features?

Evaluation and Management of Adult Headache Without Red Flags

For adults presenting with headache without red-flag features, start with a focused clinical history to distinguish between migraine and tension-type headache, then initiate stepped acute treatment beginning with NSAIDs, escalating to triptans if needed, and consider preventive therapy if headaches impair quality of life on ≥2 days per month despite optimized acute treatment. 1

Initial Clinical Assessment

Key Historical Features to Elicit

Focus your history on these specific diagnostic elements 1:

• Duration: Migraine lasts 4-72 hours; tension-type headache is variable
• Pain characteristics:
  • Migraine: unilateral (though 40% report bilateral), pulsating, moderate-to-severe intensity, worsened by routine activity
  • Tension-type: bilateral, pressing/tightening quality, mild-to-moderate intensity, not aggravated by activity
• Associated symptoms:
  • Migraine: photophobia, phonophobia, nausea/vomiting (at least one must be present)
  • Tension-type: neither nausea/vomiting nor both photophobia and phonophobia
• Aura symptoms: Visual disturbances (fortification spectra) or sensory symptoms (unilateral paresthesia) that develop over ≥5 minutes and last 5-60 minutes
• Family history: Positive in migraine (strong genetic component)
• Age of onset: Migraine typically begins at or around puberty
• Medication use: Document frequency to assess for medication-overuse headache (≥10 days/month for triptans or combinations; ≥15 days/month for simple analgesics)

Physical Examination

Perform a focused neurologic examination to confirm absence of red flags 1. Neuroimaging is not indicated for patients with normal examination and no red-flag features 2.

Acute Treatment Algorithm

Step 1: First-Line Treatment

Start with NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) 1:

• Advise early use during headache phase (most effective when taken while pain is still mild)
• Add prokinetic antiemetic (domperidone or metoclopramide) if nausea/vomiting present

Step 2: Second-Line Treatment

If NSAIDs fail after 3 consecutive attacks, add a triptan to the NSAID 3, 1:

• This represents a strong recommendation based on moderate-certainty evidence for treating moderate-to-severe migraine 3
• The combination is superior to either agent alone and reduces headache recurrence 1
• Triptans are most effective when taken early in the attack (during mild pain phase) 1
• If one triptan fails, try a different triptan before abandoning the class 1
• For rapid peak intensity or vomiting: consider subcutaneous sumatriptan 1

Important caveat: Avoid triptans in patients with cardiovascular disease or significant cardiovascular risk factors due to vasoconstrictive properties 1

Step 3: Third-Line Treatment

If all available triptans fail after adequate trial (no/insufficient response in ≥3 consecutive attacks) or are contraindicated, consider 1:

• Gepants (ubrogepant, rimegepant): CGRP receptor antagonists
• Ditans (lasmiditan): 5-HT1F agonist (safer in cardiovascular disease but causes driving impairment for ≥8 hours) 1

Medications to Avoid

Never use 1:

• Oral ergot alkaloids (poorly effective, potentially toxic)
• Opioids (questionable efficacy, high risk of dependency and medication-overuse headache)
• Barbiturates (high risk of dependency and medication-overuse headache)

Preventive Therapy Consideration

Initiate preventive treatment if headaches adversely affect the patient on ≥2 days per month despite optimized acute therapy 1. Also consider for patients overusing acute medications.

First-Line Preventive Medications 1:

• Beta-blockers (atenolol, bisoprolol, metoprolol, or propranolol)
• Topiramate
• Candesartan

Second-Line Preventive Medications 1:

• Flunarizine
• Amitriptyline
• Sodium valproate (men only—strictly contraindicated in women of childbearing potential)

Third-Line Preventive Medications 1:

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab)

Critical timing note: Assess efficacy only after 2-3 months for oral preventives, 3-6 months for CGRP antibodies, and 6-9 months for onabotulinumtoxinA 1

Common Pitfalls to Avoid

1. Medication-overuse headache: Warn patients that frequent acute medication use (≥10 days/month for triptans, ≥15 days/month for simple analgesics) risks transformation to chronic daily headache 1

2. Premature abandonment of preventive therapy: Patients often discontinue preventives before adequate trial period due to perceived inefficacy 1

3. Delayed triptan use: Triptans lose effectiveness if taken during severe pain phase; emphasize early administration 1

4. Missing tension-type headache: This is actually the most common primary headache (38% prevalence vs 12% for migraine), though migraine is more disabling and more likely to present clinically 4

5. Acetaminophen monotherapy: While you can add a triptan to acetaminophen for patients not responding to acetaminophen alone, this is a conditional recommendation with only low-certainty evidence 3

Non-Pharmacological Adjuncts

Consider as adjuncts or stand-alone when medications contraindicated 1:

• Non-invasive neuromodulatory devices
• Biobehavioral therapy
• Acupuncture (though not superior to sham acupuncture)

No evidence supports: Physical therapy, spinal manipulation, or dietary approaches 1