What is the appropriate assessment and management for a patient presenting with a headache?

Headache Assessment and Management

A thorough headache assessment requires identifying red flags for secondary headaches, classifying primary headaches based on specific diagnostic criteria, and implementing appropriate treatment strategies based on headache type and severity.

Initial Assessment

Red Flags for Secondary Headaches

• Sudden onset ("thunderclap") headache 1, 2
• New headache after age 50 1, 3
• Progressively worsening headache 1, 2
• Headache awakening patient from sleep 1
• Headache worsened by Valsalva maneuver 1
• Headache with focal neurological signs 1, 3
• Headache in patients with cancer or immunosuppression 4, 3
• Headache following head trauma 1, 3
• Headache with systemic symptoms (fever, neck stiffness) 2, 3

Key History Elements

• Onset, duration, frequency, and location of headache 1
• Pain characteristics (throbbing, pressing, severity) 1
• Associated symptoms (nausea, vomiting, photophobia, phonophobia) 1
• Aura symptoms if present 1
• Aggravating and relieving factors 1
• Medication use and possible overuse 1
• Family history of headache 1
• Triggers (foods, stress, hormonal changes) 1

Physical Examination

• Complete neurological examination 1, 2
• Vital signs with particular attention to blood pressure 5, 2
• Fundoscopic examination to check for papilledema 2, 3
• Examination of head, neck, and sinuses 2, 3

Diagnostic Classification

Migraine Without Aura

• At least 5 attacks lasting 4-72 hours 1
• At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity 1
• At least one of: nausea/vomiting, photophobia and phonophobia 1

Migraine With Aura

• At least 2 attacks with reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, retinal) 1
• Aura symptoms develop gradually over ≥5 minutes 1
• Each aura symptom lasts 5-60 minutes 1
• Aura followed by headache within 60 minutes 1

Tension-Type Headache

• Bilateral location 1
• Pressing/tightening quality (non-pulsatile) 1
• Mild to moderate intensity 1
• No aggravation with routine activity 1
• No nausea or vomiting (may have anorexia) 1

Cluster Headache

• Severe unilateral pain lasting 15-180 minutes 1
• Accompanied by ipsilateral autonomic features (lacrimation, nasal congestion, rhinorrhea, sweating, ptosis, miosis, eyelid edema) 1
• Frequency of 1-8 attacks per day 1

Chronic Migraine

• Headache on ≥15 days/month for >3 months 1
• On ≥8 days/month, headaches meet migraine criteria 1

Medication-Overuse Headache

• Headache on ≥15 days/month in a patient with pre-existing headache disorder 1
• Regular overuse of acute headache medications for >3 months 1

Neuroimaging Considerations

Neuroimaging should be considered in patients with abnormal neurological examination findings or atypical headache patterns that suggest secondary causes.

• Indications for neuroimaging: 1

  • Unexplained abnormal findings on neurological examination
  • Headache worsened by Valsalva maneuver
  • Headache that awakens patient from sleep
  • New onset headache in older adults
  • Progressively worsening headache
  • Abrupt onset of severe headache
  • Marked change in headache pattern
  • Persistent headache after head trauma

• Preferred imaging modality: 2, 3

  • Non-contrast CT scan to rule out hemorrhage
  • MRI for more detailed evaluation, especially of posterior fossa
  • Consider lumbar puncture if CT is normal but suspicion for subarachnoid hemorrhage remains high

Treatment Approach

Goals of Treatment

• Rapid and consistent relief of headache 1
• Restoration of patient's ability to function 1
• Minimizing use of backup and rescue medications 1
• Optimizing self-care 1
• Cost-effective management 1
• Minimal or no adverse effects 1

Acute Treatment for Mild to Moderate Migraine

• Non-narcotic analgesics (administer early in attack) 1, 4
• NSAIDs 1, 4
• Combination products with caffeine 1, 4
• Monitor for medication overuse headache 1

Acute Treatment for Moderate to Severe Migraine

• Triptans (5-HT1B/D agonists) - eliminate pain in 20-30% of patients by 2 hours 5, 4
  • Contraindicated in patients with cardiovascular disease or Wolff-Parkinson-White syndrome 5
  • Monitor for serotonin syndrome when used with SSRIs, SNRIs, TCAs, or MAO inhibitors 5
• Gepants (CGRP receptor antagonists) 4
• Lasmiditan (5-HT1F agonist) - safer in patients with cardiovascular risk factors 4
• Antiemetics for associated nausea/vomiting 1, 4

Preventive Treatment

• Consider for patients with:
  • ≥2 headaches per week 1
  • Chronic migraine (≥15 headache days/month) 1
• Options include: 1, 4
  • Antihypertensives
  • Antiepileptics (topiramate has evidence for chronic migraine) 1
  • Antidepressants
  • CGRP monoclonal antibodies
  • OnabotulinumtoxinA

Special Considerations

Medication Overuse Headache

• Detoxification may be necessary, including withdrawal of overused medications 1, 5
• Treatment of withdrawal symptoms 1, 5
• Implementation of appropriate preventive therapy 1, 5

Chronic Migraine Management

• Prophylactic medications are essential 1
• Topiramate has demonstrated efficacy in randomized controlled trials 1
• Consider referral to headache specialist for difficult-to-manage cases 1, 3

Patient Education

• Headache diary to track frequency, severity, triggers 1, 6
• Lifestyle modifications to avoid triggers 1, 6
• Recognition of warning signs requiring medical attention 2, 6