Approach to Headache Management
The initial approach to headache management should focus on distinguishing between primary and secondary headache disorders through careful history, physical examination, and targeted neuroimaging when red flags are present. 1, 2
Initial Assessment
History Taking
- Key questions to ask:
- Character of pain: dull, aching, throbbing, piercing, squeezing
- Location: unilateral, bilateral, frontal, occipital, behind the eyes
- Duration: hours, days, continuous
- Associated symptoms: nausea, vomiting, photophobia, phonophobia, visual disturbances
- Triggers: foods, stress, weather, hormonal changes, alcohol
- Timing patterns: frequency, time of day, awakening from sleep
- Current medications and response to treatments
- Family history of headaches 1
Physical Examination
- Complete neurological examination
- Vital signs with special attention to blood pressure
- Head and neck examination for tenderness, masses, or stiffness
- Fundoscopic examination 1, 2
Red Flags Requiring Urgent Evaluation
Identify these concerning features that suggest secondary headache:
- Sudden onset, "thunderclap" headache
- New headache after age 50
- Progressively worsening headache pattern
- Headache worsened by Valsalva maneuver or exertion
- Headache that awakens patient from sleep
- Neurological deficits or altered mental status
- Fever, neck stiffness, or rash
- History of cancer, HIV, or immunosuppression
- Recent head or neck trauma 3, 4
Diagnostic Testing
Neuroimaging
Indications for neuroimaging:
Type of imaging:
- CT scan: for acute presentations, suspected hemorrhage
- MRI: for detailed evaluation of brain parenchyma, posterior fossa 2
Additional Testing
- Lumbar puncture: when meningitis or subarachnoid hemorrhage is suspected
- Blood tests: CBC, ESR, CRP when inflammatory conditions are suspected 2
Management of Primary Headache Disorders
1. Migraine
Acute treatment:
- First-line: NSAIDs, acetaminophen, or combination with caffeine for mild-moderate attacks
- Second-line: Triptans (e.g., sumatriptan) for moderate-severe attacks
- Caution: Contraindicated in coronary artery disease, uncontrolled hypertension, and Wolff-Parkinson-White syndrome 6
- Antiemetics for associated nausea
Preventive treatment indications:
- Two or more attacks per month with disability lasting 3+ days
- Failure of or contraindication to acute treatments
- Use of acute medications more than twice weekly
- Uncommon migraine conditions (hemiplegic migraine, prolonged aura) 1
Preventive options:
- Beta-blockers
- Anticonvulsants (topiramate, valproate)
- Antidepressants (amitriptyline, fluoxetine)
- CGRP antagonists 1
2. Tension-Type Headache
- Acute treatment: NSAIDs, acetaminophen
- Preventive treatment: Amitriptyline, stress management, physical therapy
3. Cluster Headache
Acute treatment:
- High-flow oxygen (100% at 12-15 L/min via non-rebreathable mask)
- Triptans (subcutaneous sumatriptan 6mg or intranasal zolmitriptan 10mg) 7
Preventive treatment:
- Galcanezumab
- Noninvasive vagus nerve stimulation 7
Prevention of Medication Overuse Headache
- Limit acute headache medication use to no more than 2 days per week
- Monitor for increasing headache frequency in patients using acute medications
- Consider preventive therapy in patients at risk for medication overuse
- Educate patients about the risk of rebound headaches with frequent medication use 1
Follow-up and Referral
- Consider referral to neurology or headache specialist when:
- Diagnosis is uncertain
- Treatment fails despite adequate trials
- Complex comorbidities exist
- Chronic migraine is suspected (≥15 headache days/month for >3 months) 1
Common Pitfalls to Avoid
- Failing to recognize red flags suggesting secondary headache
- Overuse of neuroimaging in typical primary headache presentations
- Inadequate dosing or premature discontinuation of preventive medications
- Failure to address medication overuse
- Missing the diagnosis of chronic migraine (only 20% of patients meeting criteria are correctly diagnosed) 1, 8