What is the diagnostic workup and management plan for a patient with persistent consistent headaches?

Diagnostic Workup for Persistent Consistent Headaches

The diagnostic workup for persistent consistent headaches should begin with a thorough assessment to rule out secondary causes before establishing a diagnosis of primary headache disorder, with neuroimaging indicated only when red flags are present. 1

Initial Assessment

History Taking - Key Elements

• Pain characteristics:

  • Location (unilateral vs. bilateral)
  • Quality (pulsating, throbbing, pressure-like)
  • Severity (mild, moderate, severe)
  • Duration of episodes (hours, days)
  • Frequency (episodic vs. chronic)
  • Aggravating/relieving factors

• Associated symptoms:

  • Nausea and/or vomiting
  • Photophobia and phonophobia
  • Visual or sensory aura
  • Dizziness or vertigo
  • Autonomic symptoms (tearing, nasal congestion)

• Timing patterns:

  • Time of onset
  • Headaches that wake patient from sleep
  • Relationship to menstrual cycle
  • Pattern of progression

• Medication use:

  • Current and past treatments
  • Frequency of medication use (to identify medication overuse)
  • Response to treatments

Physical Examination

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

Red Flags Requiring Further Investigation

Neuroimaging and additional testing are indicated when these red flags are present 1, 2:

1. Sudden onset or "thunderclap" headache
2. New headache after age 50
3. Progressively worsening headache pattern
4. Headache with abnormal neurological examination
5. Headache worsened by Valsalva maneuver or exertion
6. Headache associated with systemic symptoms (fever, weight loss)
7. Headache in patients with cancer, HIV, or immunosuppression
8. New headache in pregnancy
9. Headache associated with trauma
10. Headache that awakens patient from sleep

Diagnostic Testing

When Red Flags Are Present:

1. Neuroimaging:

   • MRI brain (preferred for most situations) 2
   • CT brain (for trauma or sudden-onset headache) 2

2. Cerebrospinal Fluid Analysis:

   • Indicated for suspected:
     • Subarachnoid hemorrhage
     • CNS infection
     • Intracranial hypertension/hypotension 2

3. Blood Tests:

   • Complete blood count
   • Erythrocyte sedimentation rate (ESR)
   • C-reactive protein (CRP)
   • Basic metabolic panel
   • Thyroid function tests

When No Red Flags Are Present:

For typical primary headache presentations with normal neurological examination, neuroimaging is generally not warranted 1.

Diagnosis of Common Primary Headache Disorders

Migraine Without Aura

• At least five attacks lasting 4-72 hours
• At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity
• At least one of: nausea/vomiting, photophobia and phonophobia 3

Migraine With Aura

• At least two attacks with reversible aura symptoms
• Aura symptoms spread gradually (≥5 min)
• Each aura symptom lasts 5-60 minutes
• Headache follows aura within 60 minutes 3

Chronic Migraine

• Headache on ≥15 days/month for >3 months
• Migraine features on ≥8 days/month 3, 1

Medication Overuse Headache

• Headache on ≥15 days/month
• Regular overuse of acute headache medication
• Non-opioid analgesics ≥15 days/month or other medications ≥10 days/month for >3 months 3

Management Plan

Acute Treatment

• For mild to moderate attacks:

  • NSAIDs (ibuprofen, diclofenac, aspirin)
  • Acetaminophen/aspirin/caffeine combinations 3, 1

• For moderate to severe attacks:

  • Triptans (sumatriptan) 4
  • Combination of triptan with NSAID 3

Preventive Treatment

Indicated when:

• Headaches occur >2 times per week
• Attacks significantly impair quality of life
• Acute medications are ineffective or contraindicated
• Risk of medication overuse 1

Evidence-based preventive options:

• Topiramate
• Amitriptyline
• Propranolol
• Valproate
• OnabotulinumtoxinA (for chronic migraine) 1

Lifestyle Modifications

• Regular sleep schedule
• Regular meals
• Hydration
• Stress management
• Trigger identification and avoidance
• Regular exercise 1

Common Pitfalls to Avoid

1. Failing to recognize medication overuse headache - Can present as daily or near-daily headaches that worsen with continued medication use 1

2. Missing chronic migraine diagnosis - Only 20% of patients who fulfill criteria are correctly diagnosed 1

3. Confusing migraine aura with TIA - Migraine aura symptoms spread gradually over ≥5 minutes, while TIA symptoms have sudden onset 3

4. Misdiagnosing "sinus headache" - Often actually migraine with autonomic symptoms 1

5. Inadequate follow-up - Headache patterns can change over time, requiring reassessment of diagnosis and treatment plan

By following this systematic approach to evaluation and management, most persistent headaches can be accurately diagnosed and effectively treated, improving patient outcomes and quality of life.