What is the approach to a patient presenting with headache?

Approach to a Patient Presenting with Headache

The approach to a patient with headache must first distinguish between primary and secondary headaches through careful assessment of red flags, followed by appropriate treatment based on headache type and severity. 1

Initial Assessment

Distinguish Primary vs. Secondary Headache

1. History taking - focus on:

   • Onset characteristics (sudden vs. gradual)
   • Pain characteristics (location, quality, intensity, duration)
   • Associated symptoms (nausea, photophobia, phonophobia)
   • Exacerbating/relieving factors
   • Previous headache patterns
   • Medication use/overuse

2. Red flags requiring urgent neuroimaging: 1, 2

   • "Worst headache of life" or thunderclap onset
   • New headache pattern after age 50
   • Headache worsened by Valsalva maneuver
   • Headache that awakens patient from sleep
   • Headache with focal neurological deficits
   • Abnormal findings on neurological examination
   • Progressively worsening headache pattern
   • Headache in patients with cancer or immunosuppression
   • Headache with fever or signs of infection
   • Headache in pregnancy (consider preeclampsia, cerebral venous thrombosis)

3. Focused neurological examination:

   • Complete neuro-ophthalmologic examination (visual acuity, visual fields, fundoscopy)
   • Cranial nerve assessment
   • Motor and sensory examination
   • Coordination testing
   • Assessment for meningeal signs

Classification of Primary Headaches

Migraine

• Migraine without aura: 1

  • Recurrent attacks lasting 4-72 hours
  • At least two: unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity
  • At least one: nausea/vomiting, photophobia/phonophobia

• Migraine with aura:

  • Above features plus reversible aura symptoms (visual, sensory, speech)
  • Aura develops gradually over ≥5 minutes

• Chronic migraine:

  • Headache ≥15 days/month for >3 months
  • Migraine features on ≥8 days/month

Tension-Type Headache 3

• Pressing/tightening (non-pulsatile) quality
• Mild to moderate intensity
• Bilateral location
• No aggravation by routine activity

Cluster Headache 3

• Severe unilateral pain (orbital, supraorbital, temporal)
• Duration 15-180 minutes
• Accompanied by ipsilateral autonomic features (lacrimation, nasal congestion)

Management Approach

Acute Treatment

1. First-line for mild-moderate headaches: 1

   • NSAIDs (ibuprofen, naproxen, aspirin)
   • Acetaminophen

2. Second-line for moderate-severe attacks:

   • Triptans (sumatriptan, rizatriptan)
     • Contraindications: coronary artery disease, uncontrolled hypertension, history of stroke/TIA, Wolff-Parkinson-White syndrome 4
     • Monitor for: chest/throat/neck tightness, serotonin syndrome (when combined with SSRIs/SNRIs) 4

3. Alternative options:

   • CGRP antagonists (rimegepant, ubrogepant)
   • Dihydroergotamine
   • Lasmiditan (5-HT1F agonist) - safer in patients with cardiovascular risk factors 5

4. Adjunctive therapies: 3

   • Antiemetics for nausea
   • Sedatives for sleep disturbance

Preventive Treatment

For patients with frequent headaches (≥4 days/month): 1

• Anti-hypertensives (propranolol, metoprolol)
• Anti-epileptics (topiramate, valproate)
• Anti-depressants (amitriptyline, venlafaxine)
• Anti-CGRP monoclonal antibodies
• OnabotulinumtoxinA (for chronic migraine)

Special Considerations

Medication Overuse Headache

• Suspect when headaches occur ≥15 days/month with regular use of analgesics
• NSAIDs ≥15 days/month or triptans ≥10 days/month can cause this condition 1
• Management requires withdrawal of overused medications

Neuroimaging

• Only indicated when red flags are present 1
• Brain MRI with contrast preferred over CT for most non-emergent situations
• MR venography if venous sinus thrombosis suspected

Special Populations

• Elderly: Higher risk of secondary headache (temporal arteritis, subdural hematoma) 1
• Pregnancy: Limited medication options; acetaminophen safest for acute treatment 1
• Children: Different presentation patterns; ibuprofen for acute treatment 1

Pitfalls to Avoid

1. Failure to identify secondary headaches:

   • Always assess for red flags before assuming primary headache 6, 7
   • Consider dangerous causes like subarachnoid hemorrhage, meningitis, tumor

2. Medication overuse:

   • Regular use of acute medications can lead to chronic daily headache
   • Ask specifically about OTC medication use 8

3. Misdiagnosis of migraine:

   • Ensure headache meets diagnostic criteria before initiating migraine-specific treatment
   • Avoid triptans in patients with cardiovascular contraindications 4

4. Inadequate treatment:

   • Use appropriate doses and early intervention for better efficacy
   • Consider combination therapy for resistant cases

By following this systematic approach, clinicians can effectively diagnose headache disorders and provide appropriate treatment while avoiding potentially dangerous misdiagnoses.