Approach to Headache Management
The first step in managing a patient with headache is to distinguish between primary and secondary headache disorders through careful history, physical examination, and targeted neuroimaging when red flags are present. 1
Initial Assessment
Key History Elements
- Pain characteristics: location, quality, severity, duration
- Associated symptoms: nausea, photophobia, phonophobia, aura
- Timing patterns: onset, frequency, time of day
- Triggers and alleviating factors
- Current medications and response to treatments
- Family history of headaches
Physical Examination
- Complete neurological examination
- Vital signs (especially blood pressure)
- Head and neck examination
- Fundoscopic examination
Red Flags Requiring Immediate Attention
- SNOOP4 mnemonic for concerning features:
- Systemic symptoms (fever, weight loss)
- Neurological signs or symptoms
- Onset sudden or abrupt ("thunderclap")
- Older age (new headache after age 50)
- Pattern change or progression
- Positional triggers
- Precipitated by Valsalva/exertion
- Papilledema
Neuroimaging Indications 1, 2
- Unexplained abnormal neurological examination
- New onset headache in older persons (>50 years)
- Progressively worsening headache pattern
- Headache with atypical features
- Recent head or neck injury
- Headache brought on by exertion or Valsalva maneuver
- History of cancer or immunocompromised state
Treatment Approach
Acute Treatment 1
First-line for mild-moderate attacks:
- NSAIDs
- Acetaminophen
- Combination with caffeine
Second-line for moderate-severe attacks:
- Triptans (with important contraindications)
- High-flow oxygen (especially for cluster headache)
Important Triptan Contraindications 3
- Coronary artery disease
- Prinzmetal's variant angina
- Wolff-Parkinson-White syndrome
- History of stroke or TIA
- Uncontrolled hypertension
- Concurrent use of MAO inhibitors
- Caution with SSRIs/SNRIs (risk of serotonin syndrome)
Preventive Treatment 1
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
Options:
- Beta-blockers
- Anticonvulsants
- Antidepressants
- CGRP antagonists
- Galcanezumab
- Noninvasive vagus nerve stimulation
Medication Overuse Considerations
- Limit acute headache medication use to no more than 2 days per week 1
- Monitor for increasing headache frequency in patients using acute medications
- Medication overuse headache may present as migraine-like daily headaches or increased frequency of attacks 3
- Detoxification may be necessary, including withdrawal of overused drugs 3
Referral Criteria 1
- Uncertain diagnosis
- Treatment failure despite adequate trials
- Complex comorbidities
- Suspected chronic migraine
Common Pitfalls to Avoid 1
- 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
Special Considerations
- Triptans can cause non-coronary vasospastic reactions and significant elevation in blood pressure 3
- Serotonin syndrome risk increases with concurrent use of SSRIs, SNRIs, TCAs, and MAO inhibitors 3
- Anaphylactic/anaphylactoid reactions can occur with triptans and may be life-threatening 3
- Seizures have been reported following triptan administration, use with caution in patients with history of epilepsy 3
By following this structured approach, clinicians can effectively differentiate between primary and secondary headache disorders and implement appropriate management strategies to improve patient outcomes.