What is the recommended approach for investigating and managing morning headaches?

Investigating Morning Headaches

Morning headaches require a systematic evaluation focused on identifying red flags that may indicate secondary causes, with neuroimaging only needed when these red flags are present. 1, 2

Initial Assessment

Key History Elements to Obtain

• Timing: Onset, duration, frequency, and pattern (especially early morning waking or prominence upon waking) 2, 3
• Pain characteristics: Location, quality, severity, aggravating/relieving factors 1, 2
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia, focal neurological deficits 1, 2
• Medication use: Current acute and preventive medications, potential medication overuse 1, 2
• Sleep patterns: Sleep apnea symptoms, insomnia, sleep quality 3

Red Flag Symptoms Requiring Further Investigation

• Thunderclap headache (sudden onset, worst headache of life) 1, 2
• New onset after age 50 2
• Progressively worsening headache pattern 2, 4
• Headache awakening patient from sleep 5
• Headache worsened with Valsalva maneuver 2, 5
• Associated fever or neck stiffness 2
• Focal neurological deficits 1, 2
• Papilledema on examination 3, 4
• Recent head or neck trauma 5
• History of cancer or immunocompromised state 2, 5

Diagnostic Tools

Physical Examination

• Complete neurological examination 1, 2
• Vital signs 2
• Fundoscopic examination (to check for papilledema) 2
• Neck examination for stiffness 2

Diagnostic Aids

• Headache diaries and calendars to track patterns and frequency 1, 2
• Screening questionnaires:
  • Three-item ID-Migraine questionnaire 1, 2
  • Five-item Migraine Screen Questionnaire (MS-Q) 1, 2

Diagnostic Testing

Neuroimaging

• Only indicated when red flags are present 1, 2
• CT without contrast if intracranial hemorrhage is suspected 2
• MRI preferred for most other concerning causes of headache 2
• Avoid unnecessary imaging in the absence of red flags 1

Additional Testing (When Indicated)

• Blood tests for suspected systemic conditions 5, 6
• Lumbar puncture if meningitis or subarachnoid hemorrhage is suspected 5, 4
• Sleep study if sleep apnea is suspected 3

Common Causes of Morning Headaches

Primary Headache Disorders

• Migraine (often worse in the morning) 1, 2
• Tension-type headache 4
• Cluster headache (can awaken patients from sleep) 1

Secondary Causes

• Medication overuse headache (particularly important to assess) 1, 2, 3
• Sleep disorders (sleep apnea, insomnia) 3
• Depression and anxiety 3
• Raised intracranial pressure (brain tumor, idiopathic intracranial hypertension) 3
• Cervicogenic headache 5
• Temporomandibular joint dysfunction 6

Management Approach

For Primary Headaches

1. Acute treatment:

   • NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-550mg) as first-line 2
   • Triptans as second-line for migraine 2

2. Preventive treatment (if headaches occur ≥2 times/week):

   • Topiramate, beta-blockers, or tricyclic antidepressants 2
   • OnabotulinumtoxinA for chronic migraine 2

For Secondary Headaches

• Treat the underlying cause 7, 6
• Address medication overuse by limiting acute headache medications to ≤2 days/week 2
• Manage sleep disorders with appropriate interventions 3

Common Pitfalls to Avoid

• Assuming all morning headaches are due to brain tumors 3
• Overlooking medication overuse as a common cause 1, 2, 3
• Failing to recognize red flags in patients with known primary headache disorders 2
• Overusing neuroimaging when not indicated by red flags 1, 2
• Using opioids or barbiturates for headache management 2

Morning headaches are common and often benign, but a systematic approach focusing on identifying red flags is essential to distinguish between primary and secondary causes requiring further investigation.