What is the workup for unilateral headaches in a 26-year-old patient?

From the Guidelines

The workup for unilateral headaches in a 26-year-old patient should begin with a thorough history and physical examination to identify potential causes and red flags, as recommended by the most recent guidelines 1.

Key Components of the Workup

• A detailed history to identify headache characteristics (onset, duration, severity, frequency), associated symptoms (nausea, photophobia, aura), triggers, and family history, which can help suspect migraine without aura or with aura, as suggested by 1.
• Physical examination should focus on vital signs, neurological assessment, and examination of the head and neck to rule out secondary causes.
• Initial diagnostic testing should include basic laboratory studies such as complete blood count, comprehensive metabolic panel, and inflammatory markers (ESR, CRP) to rule out systemic causes.

Neuroimaging and Specialized Testing

• Neuroimaging with MRI brain with and without contrast is preferred over CT to evaluate for structural abnormalities, though CT may be used if MRI is unavailable or in emergency situations, as suggested by 1.
• Additional specialized testing may include lumbar puncture if meningitis or subarachnoid hemorrhage is suspected, or ophthalmologic evaluation if increased intracranial pressure is suspected.

Diagnostic and Therapeutic Trials

• For suspected migraines, a trial of abortive therapy with NSAIDs (ibuprofen 400-600mg) or triptans (sumatriptan 50-100mg orally) may be diagnostic and therapeutic, as recommended by 1.
• If cluster headaches are suspected, high-flow oxygen (12-15 L/min for 15 minutes) can be both diagnostic and therapeutic.

Preventive Medications

• Preventive medications should be considered for frequent or debilitating headaches, with options including propranolol (20-160mg daily), topiramate (25-100mg twice daily), or amitriptyline (10-150mg at bedtime), as suggested by 1. This systematic approach helps differentiate between primary headache disorders (migraines, cluster headaches, tension headaches) and secondary causes that require specific treatment, ultimately improving morbidity, mortality, and quality of life for the patient 1.

From the Research

Unilateral Headaches in a 26-year-old Patient

The workup for unilateral headaches in a 26-year-old patient involves a focused history and physical examination to identify secondary headache and determine the need for immediate referral to the emergency department or a non-emergent referral to a neurologist 2.

Key Steps in the Workup

• Proper categorization of the primary headache
• Attention to lifestyle and psychosocial factors
• Prescription of analgesics for acute pain relief
• Use of preventive medication when indicated
• Consideration of secondary headache and medication overuse headache in patients on long-term analgesics with unremitting headache 2, 3, 4

Diagnostic Testing

• Imaging is generally not warranted, but may be considered in certain cases, such as suspected secondary headache or abnormal neurologic examination 3, 5
• A headache diary can be useful in documenting headache frequency, symptoms, and treatment response over time 4
• Neurologic assessment and physical examination focused on the head and neck are indicated in all patients 4

Specific Considerations

• Cluster headache is a strictly unilateral headache with cranial autonomic features and can be classified as episodic or chronic 6
• Medication overuse headache should be suspected in patients with frequent headaches and a history of long-term analgesic use 2, 4
• Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy 4