What should be done if a patient presents with a headache?

Management of Headache in Primary Care

When a patient presents with a headache, the first step is to rule out secondary causes through careful history taking and examination for "red flags" before proceeding with appropriate treatment based on headache type and severity. 1

Initial Assessment

• Evaluate for "red flags" that suggest secondary headache requiring urgent attention: 1, 2

  • Sudden/severe onset ("first or worst" headache)
  • Headache worsened by Valsalva maneuver
  • Headache that awakens patient from sleep
  • New onset in older person (>50 years)
  • Progressive worsening pattern
  • Focal neurologic deficits
  • Altered mental status
  • Fever or signs of infection
  • History of cancer or immunosuppression
  • Pregnancy or recent pregnancy
  • Coagulopathy

• Ask key diagnostic questions to determine headache type: 1

  • Location (unilateral, bilateral, specific regions)
  • Character (throbbing, pressing, stabbing)
  • Intensity (mild, moderate, severe)
  • Duration (hours, days)
  • Associated symptoms (nausea, vomiting, photophobia, phonophobia)
  • Triggers (foods, stress, hormonal changes)
  • Previous treatments and their effectiveness

Neuroimaging Guidelines

• Neuroimaging (CT or MRI) is indicated when: 1

  • Unexplained abnormal findings on neurologic examination
  • Headache with concerning features (sudden onset, progressively worsening)
  • New onset in patients over 50 years
  • Atypical features that don't fit established primary headache patterns

• Neuroimaging is generally not warranted for patients with: 1

  • Normal neurologic examination
  • Features consistent with primary headache disorders
  • Long history of similar headaches without change in pattern

Management Based on Headache Type

For Migraine Headache:

• Acute treatment options: 1, 3

  • For mild to moderate migraines: NSAIDs, acetaminophen, or combination products with caffeine
  • For moderate to severe migraines: Triptans (5-HT1B/D agonists) - avoid in patients with cardiovascular disease
  • Alternative options for those who cannot take triptans: Gepants (CGRP antagonists) or lasmiditan (5-HT1F agonist)
  • Administer early in the attack for best results

• Preventive treatment (for frequent migraines): 1, 3

  • Consider prophylaxis if headaches occur more than twice weekly
  • Evidence-based options include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate
  • OnabotulinumtoxinA (Botox) is FDA-approved for chronic migraine prophylaxis

For Chronic Migraine (≥15 headache days/month):

• Diagnosis requires 15+ headache days per month for >3 months, with migraine features on at least 8 days 1
• Use headache diary to accurately track frequency and characteristics 1
• Treatment should include both prophylactic and acute medications 1
• OnabotulinumtoxinA is specifically approved for chronic migraine prophylaxis 1
• Address modifiable risk factors: medication overuse, caffeine use, sleep disorders, stress 1

For Cluster Headache:

• Characterized by severe unilateral pain lasting 15-180 minutes with ipsilateral autonomic symptoms 4
• Occurs in clusters with frequency of 1-8 attacks daily 4
• Refer to neurologist for specialized management 5

Special Considerations

• Avoid medication overuse: Limit use of acute medications to prevent medication-overuse headache 1, 6
• Avoid opioids: Not recommended for regular headache management due to risk of dependency and rebound headaches 1, 6
• Consider referral to neurologist for: 5
  • Cluster headaches
  • Uncertain diagnosis
  • Poor response to preventive strategies
  • Migraine with persistent aura
  • Headache with motor weakness

Patient Education

• Maintain a headache diary to track frequency, severity, triggers, and treatment response 1
• Identify and avoid personal triggers 1
• Establish regular sleep patterns 1
• Consider stress management techniques 1
• Understand proper medication use to avoid rebound headaches 1

By following this structured approach to headache evaluation and management, primary care providers can effectively diagnose and treat most headache disorders while appropriately identifying patients who require neuroimaging or specialist referral.