What is the approach to diagnosing and managing headaches for a 4th year Bachelor of Medicine, Bachelor of Surgery (MBBS) student?

Approach to Diagnosing and Managing Headaches

The diagnosis and management of headaches requires a systematic approach focused on distinguishing primary headache disorders from potentially life-threatening secondary causes, with treatment tailored to the specific headache type to reduce morbidity and mortality. 1

Diagnostic Approach

Step 1: Initial Assessment and Classification

• Primary Headache Types:
  • Migraine without aura: Recurrent moderate to severe headache with at least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity; AND at least one of: nausea/vomiting, photophobia and phonophobia 1
  • Migraine with aura: Includes visual, sensory, speech/language, motor, brainstem, or retinal symptoms that develop gradually and precede or accompany headache 1
  • Tension-type headache: Bilateral, pressing/tightening (non-pulsating) pain of mild/moderate intensity without aggravation by routine physical activity 1
  • Cluster headache: Severe unilateral pain lasting 15-180 minutes with ipsilateral autonomic features (lacrimation, nasal congestion, etc.) 1

Step 2: Red Flag Screening

Critical red flags requiring immediate evaluation: 1, 2, 3

• Thunderclap headache (sudden onset of worst headache)
• Focal neurologic deficits or papilledema
• Fever with meningeal signs (neck stiffness)
• New headache in immunocompromised patients
• Headache worsening with Valsalva maneuvers or exercise
• New headache after age 50
• Personality changes or altered mental status
• Headache following trauma

Step 3: Diagnostic Workup

• For primary headaches: Diagnosis is primarily clinical based on ICHD-3 criteria 1
• For suspected secondary headaches:
  • Emergent situations: Non-contrast head CT to exclude hemorrhage; lumbar puncture if CT normal but subarachnoid hemorrhage suspected 2, 3
  • Non-emergent with concerning features: MRI brain (preferred over CT due to higher resolution) 1
  • Important: Neuroimaging is NOT routinely indicated for typical primary headache presentations without red flags 1

Management Approach

Step 1: Acute Treatment of Migraine

• First-line: NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) 1

  • Take early in the headache phase for maximum effectiveness

• Second-line: Triptans (e.g., sumatriptan) 1, 4

  • Contraindicated in patients with:
    • Coronary artery disease or Prinzmetal's angina
    • History of stroke or TIA
    • Uncontrolled hypertension
    • Wolff-Parkinson-White syndrome
  • Monitor for chest/throat/neck tightness (usually non-cardiac)

• Adjunct treatment: Prokinetic antiemetics (domperidone, metoclopramide) for nausea/vomiting 1

• Medications to avoid: Ergot alkaloids, opioids, and barbiturates due to questionable efficacy and risk of dependency 1

Step 2: Preventive Treatment

• Consider preventive therapy when:

  • Migraine attacks significantly impair quality of life despite optimized acute therapy
  • Patient experiences ≥2 disabling headache days per month
  • Patient has medication overuse headache

• Important monitoring considerations:

  • Efficacy of oral preventives should be assessed after 2-3 months
  • For CGRP monoclonal antibodies, assess after 3-6 months
  • For onabotulinumtoxinA, assess after 6-9 months

Step 3: Medication Overuse Headache Prevention

• Definition: Headache occurring on ≥15 days/month in a patient with pre-existing headache disorder, with regular overuse of acute headache medications 1

  • Non-opioid analgesics: ≥15 days/month for ≥3 months
  • Other acute medications: ≥10 days/month for ≥3 months

• Management: Requires withdrawal of overused medications and treatment of withdrawal symptoms 4

Patient Education

• Explain that migraine is not curable but can be controlled
• Set realistic expectations: goal is to reduce attack frequency, duration, and intensity
• Discuss proper medication use and potential side effects
• Identify and manage potential triggers (sleep quality, stress, certain foods)
• Use headache diaries to track patterns and medication effectiveness

Common Pitfalls to Avoid

1. Overuse of neuroimaging: Reserve for patients with red flags or suspected secondary headache 1

2. Misdiagnosis of migraine as sinus headache: Recurrent "sinus headaches" are often migraines 1

3. Inadequate treatment of acute attacks: Treat early with appropriate dose to prevent central sensitization 1

4. Medication overuse: Limit acute medication use to prevent medication overuse headache 1, 4

5. Failure to recognize dangerous secondary headaches: Always evaluate for red flags 3, 5

6. Overlooking comorbidities: Anxiety, depression, and sleep disorders often coexist with headache disorders 1