What is the initial evaluation and management for complaints of headaches?

Initial Evaluation and Management for Complaints of Headaches

The initial evaluation of headaches must include a thorough assessment of headache characteristics, associated symptoms, and red flags to distinguish between primary and secondary causes, with neuroimaging only indicated when red flags are present. 1

Key Components of Headache Evaluation

History Taking - Essential Elements

• Timing and pattern: Onset, duration, frequency, and time of day (morning vs. evening)
• Pain characteristics: Location, quality, intensity, and aggravating/alleviating factors
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia, aura
• Red flags (SNNOOP10): 1, 2
  • Systemic symptoms (fever, weight loss)
  • Neurologic symptoms or signs
  • New onset after age 50
  • Onset that is sudden or abrupt (thunderclap)
  • Onset during pregnancy or postpartum
  • Precipitated by exertion, sexual activity, or Valsalva
  • Positional headache
  • Progressive headache or new daily persistent headache
  • Prior history of cancer or immunocompromised state
  • Papilledema
  • Headache awakening patient from sleep

Physical Examination

• Vital signs (including blood pressure)
• Complete neurological examination
• Fundoscopic examination to check for papilledema
• Examination of head, neck, and temporomandibular joints
• Assessment for meningeal signs

Diagnostic Classification

Primary Headache Types 3, 1

1. Migraine

   • At least two of: unilateral location, throbbing character, moderate to severe intensity, worsening with activity
   • At least one of: nausea/vomiting, photophobia and phonophobia
   • Duration: 4-72 hours untreated

2. Tension-type headache

   • At least two of: pressing/tightening quality, mild to moderate intensity, bilateral location, no aggravation with activity
   • No nausea/vomiting (may have anorexia)
   • No photophobia AND phonophobia (may have one)

3. Cluster headache

   • Severe unilateral pain (orbital, supraorbital, temporal)
   • Duration: 15-180 minutes untreated
   • Associated with ipsilateral autonomic features (lacrimation, nasal congestion, etc.)

Secondary Headache Considerations

• Medication overuse headache
• Intracranial pathology (hemorrhage, mass, infection)
• Cervicogenic headache
• Temporomandibular joint dysfunction
• Sleep disorders (sleep apnea)
• Systemic conditions (hypertension, infection)

Diagnostic Testing

When to Order Neuroimaging 1, 2

• Only indicated when red flags are present
• CT without contrast: First choice for suspected intracranial hemorrhage
• MRI: Preferred for most other concerning causes of headache

Additional Testing Based on Suspicion

• Blood tests: For suspected systemic conditions
• Lumbar puncture: For suspected meningitis or subarachnoid hemorrhage with negative CT
• Sleep study: For suspected sleep apnea

Management Approach

Acute Treatment 3, 1

1. First-line options:

   • NSAIDs: Ibuprofen 400-800mg, naproxen sodium 500-550mg, aspirin 900-1000mg
   • Acetaminophen: For those who cannot take NSAIDs

2. Second-line options for migraine:

   • Triptans (contraindicated in cardiovascular disease, uncontrolled hypertension)
   • Antiemetics for associated nausea

3. Avoid:

   • Opioids and barbiturates (risk of dependency, poor efficacy)
   • Oral ergot alkaloids (poor efficacy, potential toxicity)

Preventive Treatment 1

• Indicated when headaches occur >2 times/week or ≥15 days/month
• Options include:
  • Topiramate
  • Beta-blockers
  • Tricyclic antidepressants
  • OnabotulinumtoxinA (for chronic migraine)

Non-pharmacological Approaches 1

• Regular sleep schedule
• Regular meals and hydration
• Stress management techniques
• Trigger identification and avoidance
• Regular exercise

Common Pitfalls to Avoid

1. Overuse of neuroimaging when red flags are absent, leading to unnecessary radiation exposure and costs 1, 2

2. Medication overuse headache - Limit acute medications to ≤2 days/week to prevent this complication 1

   • NSAIDs: Risk if used ≥15 days/month
   • Triptans: Risk if used ≥10 days/month

3. Misdiagnosis of migraine as sinus headache - Recurrent "sinus headaches" are often migraines 2

4. Failure to recognize dangerous secondary causes - Always assess for red flags before concluding primary headache 1, 4

5. Inadequate documentation of headache patterns - Consider using headache diaries to track frequency, severity, and response to treatment 1