What is the best approach to manage a patient with headaches?

From the Guidelines

The best approach to managing a patient with headaches begins with a thorough diagnosis to determine the headache type, as treatment varies significantly between migraine, tension, cluster, or secondary headaches. Initial management should include a detailed history, physical examination, and headache diary to identify triggers, as recommended by 1. For acute migraine treatment, first-line medications include NSAIDs (ibuprofen 400-600mg or naproxen 500-550mg) or acetaminophen 1000mg, as suggested by 1. If these are ineffective, triptans such as sumatriptan (50-100mg orally, or 6mg subcutaneously) can be used.

Key Considerations

• For frequent or severe migraines, preventive therapy should be considered, including topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies, as recommended by 1.
• Tension headaches typically respond to NSAIDs, while cluster headaches may require oxygen therapy (100% at 12-15L/min) or sumatriptan injections.
• Non-pharmacological approaches are essential for all headache types, including stress management, regular sleep patterns, hydration, and trigger avoidance.
• Patients should be educated about medication overuse headaches, which can develop when acute medications are used more than 10-15 days per month, as warned by 1.

Red Flags

• Certain red flags like sudden-onset severe headache, neurological deficits, or headaches that worsen with Valsalva maneuvers require immediate medical attention to rule out secondary causes.

Follow-Up

• Regular follow-up is important to assess treatment efficacy and adjust therapy as needed, taking into account the patient's history, response to, and tolerance for specific medications, as well as coexisting conditions, as considered by 1.

From the FDA Drug Label

Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions.

The best approach to manage a patient with headaches is to exclude other potentially serious neurological conditions before treating the headaches, especially in patients not previously diagnosed as migraineurs or those presenting with atypical symptoms.

• Key considerations include:
  • Evaluating for cerebrovascular events, such as stroke or TIA
  • Assessing for cardiac risk factors and performing a cardiovascular evaluation if necessary
  • Monitoring for signs of serotonin syndrome, particularly when co-administering with other serotonergic medications
  • Being cautious in patients with a history of epilepsy or conditions associated with a lowered seizure threshold
  • Avoiding medication overuse headache by limiting the use of acute migraine drugs to less than 10 days per month 2, 2, 2

From the Research

Approach to Managing a Patient with Headaches

To manage a patient with headaches effectively, it is crucial to follow a systematic approach that includes a thorough history, physical examination, and appropriate diagnostic testing when necessary. The key steps in this approach are outlined below:

• History and Physical Examination: A focused history and physical examination are essential to identify secondary headache and determine whether an immediate referral to the emergency department or a non-emergent referral to a neurologist is warranted 3.
• Categorization of Headache: Proper categorization of the primary headache is important, including attention to lifestyle and psychosocial factors 3.
• Diagnostic Testing: Thoughtful testing can exclude worrisome underlying causes, and the specific diagnostic studies recommended include neuroimaging, cerebrospinal fluid examination, and blood testing in specific situations 4.
• Red Flags: It is essential to screen for headache "red flags" that can suggest life-threatening secondary etiologies, such as recent head or neck injury, new or worsening headache, and neurological symptoms or abnormal signs 4, 5.
• Referral to a Neurologist: Patients with certain types of headaches, such as cluster headaches, headaches of uncertain diagnosis, or poor response to preventive strategies, should be referred to a neurologist 3.
• Management of Primary Headaches: Most patients with primary headaches can be safely managed in the outpatient setting with prescription of analgesics for acute pain relief and the use of preventive medication when indicated 3.

Considerations for Secondary Headaches

Secondary headaches can be caused by underlying conditions that require prompt diagnosis and treatment. The following considerations are important:

• Dangerous Secondary Etiologies: A thorough history and physical examination, along with a comprehensive differential diagnosis, may alert a physician to the diagnosis of a secondary headache 5.
• Evaluation and Workup: Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated 5.
• Headache Emergencies: Headaches can be symptomatic of an underlying process that requires prompt diagnosis and urgent treatment to reduce threats to life or limb, and careful attention to patients' history and physical examination is crucial in these cases 6.