How to assess and manage a patient with consistent and persistent headaches?

Assessment and Management of Persistent Headaches

A thorough headache assessment must first rule out secondary causes before establishing a diagnosis of primary headache disorder and implementing appropriate treatment strategies.

Initial Assessment

Key History Elements

• Character of pain: Dull, aching, throbbing, piercing, squeezing, or excruciating 1
• Location: Unilateral or bilateral, front or back of head, over or behind one eye 1
• Duration: Hours, days, frequency pattern 1
• Associated symptoms: Nausea, vomiting, dizziness, photophobia, phonophobia 1
• Timing: Relationship to menstrual cycle, time of day, sleep patterns 1
• Triggers: Food, beverages, stress, weather, odors, missed meals 1
• Medication use: Current over-the-counter or prescription medications and effectiveness 1
• Family history: Headache patterns in relatives 1

Red Flag Symptoms Requiring Urgent Evaluation

• Thunderclap headache (sudden onset, severe intensity) 2
• Headache worsened with Valsalva maneuver 1
• Headache that awakens from sleep 1
• New onset in older person (>50 years) 2
• Progressively worsening headache 1
• Headache with focal neurologic deficits 2
• Headache with fever or immunosuppression 2
• Headache following head trauma 2
• Headache with impaired memory or altered mental status 2

Physical Examination Focus

• Complete neurological examination
• Vital signs (especially blood pressure)
• Head and neck examination
• Assessment for meningeal signs

Diagnostic Approach

Neuroimaging Guidelines

• Indicated for:

  • Abnormal neurological examination findings 1
  • Headache with atypical features 1
  • Headache worsened with Valsalva maneuver 1
  • Headache that awakens patient from sleep 1
  • New onset headache in older person 1
  • Progressively worsening headache 1

• Not typically warranted for:

  • Normal neurological examination with typical primary headache features 1

Diagnostic Tools

• Headache diary to track frequency, intensity, duration, and triggers 1
• Simple screening question: "Do you feel like you have a headache of some type on 15 or more days per month?" 1

Management Strategy

Primary Headache Treatment Principles

1. Acute treatment to abort attacks
2. Preventive treatment to reduce frequency and severity
3. Trigger identification and management
4. Medication overuse prevention

Acute Treatment Options

• For mild to moderate migraines:

  • NSAIDs (administered early in attack) 1
  • Combination of acetaminophen, aspirin, and caffeine 1

• For moderate to severe migraines:

  • Triptans (e.g., sumatriptan) - shown to provide headache response in 50-62% of patients at 2 hours and 65-79% at 4 hours 3
  • Consider parenteral options for severe attacks (e.g., ketorolac) 1

Preventive Treatment

• Indicated when:

  • Patient has more than two headaches per week 1
  • Headaches on ≥15 days/month for >3 months (chronic migraine) 1, 2

• Evidence-based options:

  • Topiramate (strongest evidence for chronic migraine) 1
  • Other options: gabapentin, tizanidine, fluoxetine, amitriptyline, valproate 1
  • OnabotulinumtoxinA (FDA-approved for chronic migraine prophylaxis) 1

Managing Modifiable Risk Factors

• Obesity management 1
• Medication overuse identification and correction 1
• Caffeine reduction 1
• Sleep apnea screening and treatment 1
• Addressing psychiatric comorbidities 1
• Stress management 1

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache: Frequent use of ergotamine, opiates, analgesics, or triptans (≥10 days/month) can lead to rebound headaches 1, 3
• Misdiagnosing "sinus headache" when symptoms are actually migraine 2
• Confusing migraine aura with TIA: Migraine aura typically spreads gradually (≥5 min) while TIA symptoms have sudden onset 2
• Missing chronic migraine diagnosis: Only 20% of patients who fulfill criteria are correctly diagnosed 1
• Overlooking vestibular migraine: Consider in patients with dizziness even without current headache 2

Referral Considerations

Refer to neurologist or headache specialist for:

• Uncertain diagnosis
• Poor response to standard treatments
• Cluster headache
• Migraine with persistent aura
• Headache with motor weakness
• Secondary headache concerns

By following this structured approach to headache assessment and management, clinicians can effectively identify concerning features requiring further investigation while providing appropriate treatment for primary headache disorders.