Laboratory Tests and Medications for Persistent Headaches
For patients with persistent headaches, recommended laboratory tests should include complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and basic metabolic panel, while first-line medication treatment should begin with NSAIDs such as ibuprofen or naproxen, with triptans as second-line therapy for those with suspected migraine. 1, 2
Initial Diagnostic Approach
Laboratory Tests
- Complete blood count (CBC): To evaluate for anemia or infection
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): To screen for inflammatory conditions, particularly temporal arteritis in patients over 50 2, 3
- Basic metabolic panel: To assess for electrolyte abnormalities or renal dysfunction
- Thyroid function tests: To rule out thyroid disorders that may present with headache
Important: Normal inflammatory markers do not rule out temporal arteritis. In one study, up to 16% of patients with biopsy-proven giant cell arteritis had normal ESR at initial presentation 3, 4
Imaging Studies (when red flags are present)
- MRI brain with contrast: First-line imaging when secondary headache is suspected 1
- CT head without contrast: For sudden severe headache to evaluate for subarachnoid hemorrhage 2
- MRA/MRV: Only indicated when vascular abnormalities are suspected 1
Red Flags Requiring Urgent Evaluation
- Thunderclap headache (sudden onset, severe intensity)
- Headache onset after age 50
- Focal neurological symptoms or signs
- Systemic symptoms (fever, weight loss)
- Change in headache pattern or character
- Headache worsened by Valsalva maneuver or positional changes
- Immunocompromised state
- History of cancer
- Neck stiffness or meningeal signs 2, 1
Medication Management
First-Line Treatment
- NSAIDs: Ibuprofen (400-800mg), naproxen sodium (500-550mg), or aspirin (900-1000mg) 1
- Most consistent evidence supports these agents for initial treatment
- Take early in the headache phase for maximum effectiveness
Second-Line Treatment (for inadequate response to NSAIDs)
- Triptans: Sumatriptan, rizatriptan, zolmitriptan 1
Adjunct Medications
- Antiemetics: Metoclopramide or domperidone for associated nausea/vomiting 1
- Non-oral routes: Consider when significant nausea/vomiting is present 1
Preventive Therapy (when indicated)
Indicated when:
- Headaches occur ≥2 times per month with significant disability
- Acute treatments are ineffective or contraindicated
- Medication overuse is present or at risk 1, 2
Preventive Medication Options
Topiramate: Effective for migraine prevention, starting at 25mg daily and gradually increasing to 100mg daily 5
- Monitor for metabolic acidosis, particularly at doses >200mg/day
- Other side effects include paresthesias, cognitive slowing, and weight loss
Beta-blockers: Propranolol or metoprolol
- Contraindicated in asthma, bradycardia, and heart block
Tricyclic antidepressants: Amitriptyline starting at 10mg nightly
- Side effects include sedation, dry mouth, and constipation
Medication Overuse Considerations
- Limit acute headache medications to ≤2 days per week to prevent medication overuse headache 1
- Medication overuse headache should be suspected when:
- NSAIDs are used ≥15 days/month
- Triptans, ergotamines, or combination analgesics are used ≥10 days/month 2
Important Cautions
- Avoid opioids and barbiturates for headache management due to questionable efficacy, significant adverse effects, and risk of dependency 1
- Avoid oral ergot alkaloids due to poor efficacy and potential toxicity 1
- Monitor for medication overuse headache, which can develop from frequent use of acute medications 1
- Be vigilant for secondary headache causes in patients over 50 with new-onset headache, even with normal inflammatory markers initially 3, 4
Follow-up Recommendations
- Reassess effectiveness of acute treatment after 2-3 trials
- For preventive medications, evaluate efficacy after 2-3 months of treatment
- Consider specialist referral for headaches refractory to first- and second-line treatments