What is the appropriate evaluation and management of a headache?

Evaluation and Management of Headache

The appropriate evaluation of headache requires identification of red flags for secondary headaches, thorough history assessment, and targeted neuroimaging only when indicated by concerning features. 1, 2

Initial Assessment

Key History Elements

• Assess onset characteristics (sudden vs. gradual), duration, frequency, and location of headache 3, 1
• Evaluate pain characteristics, associated symptoms, aggravating/relieving factors, and medication use 3, 4
• Document presence of aura symptoms, family history, and potential triggers 1, 4
• Determine if headache awakens patient from sleep, which may indicate increased intracranial pressure 2
• Ask if headache is worsened by Valsalva maneuver, which may suggest secondary causes 2

Red Flags Requiring Immediate Attention

• Thunderclap headache (sudden onset reaching maximum intensity within seconds to minutes) 2
• "Worst headache of life" description by patient 2
• New headache onset after age 50 4, 2
• Progressive worsening pattern over time 4, 2
• Headache associated with fever, neck stiffness, or altered mental status 2
• Focal neurological symptoms or signs 2
• Headache following recent head trauma 2
• Headache with associated weight loss or personality changes 2

Diagnostic Classification

Primary Headache Types

• Migraine without aura: at least 5 attacks lasting 4-72 hours with at least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity; and at least one of: nausea/vomiting, photophobia and phonophobia 3, 1
• Migraine with aura: at least 2 attacks with reversible aura symptoms developing gradually over ≥5 minutes, each lasting 5-60 minutes, followed by headache within 60 minutes 1
• Tension-type headache: bilateral location, pressing/tightening quality, mild to moderate intensity, no aggravation with routine activity, and no nausea or vomiting 3, 1
• Cluster headache: severe unilateral pain lasting 15-180 minutes with ipsilateral autonomic features (lacrimation, nasal congestion, ptosis) 3

Neuroimaging Guidelines

When Neuroimaging Is Indicated

• Unexplained abnormal findings on neurological examination 4, 2
• Headache worsened by Valsalva maneuver 4, 2
• Headache that awakens patient from sleep 4, 2
• New onset headache in older adults (>50 years) 4, 2
• Progressively worsening headache pattern 4, 2
• Abrupt onset of severe headache 2
• Marked change in previously stable headache characteristics 2

When Neuroimaging Is Not Indicated

• Normal neurologic examination with features consistent with primary headache disorders 3, 4
• Long history of similar headaches without change in pattern 4
• Absence of red flag symptoms 3, 4

Imaging Modality Selection

• MRI is preferred over CT due to higher resolution and absence of radiation exposure 2
• CT without contrast is recommended when acute intracranial hemorrhage is suspected 2
• For patients with acute onset of severe headache who present >6 hours from symptom onset or who have a new neurological deficit, a noncontrast head CT followed by lumbar puncture if negative is recommended 2

Treatment Approach

Acute Treatment for Migraine

• Mild to moderate migraine: non-narcotic analgesics, NSAIDs, and combination products with caffeine 1, 5
• Moderate to severe migraine: triptans (5-HT1B/D agonists), which eliminate pain in 20-30% of patients by 2 hours 5
  • Caution: Triptans may cause coronary artery vasospasm and are contraindicated in patients with CAD or Prinzmetal's angina 6, 7
  • Monitor for serotonin syndrome when combining with SSRIs or SNRIs 6, 7
• Newer options include gepants (CGRP antagonists) and lasmiditan (5-HT1F agonist), which may be safer in patients with cardiovascular risk factors 5

Preventive Treatment

• Consider prophylaxis if headaches occur more than twice weekly 4
• Evidence-based options include antihypertensives, antiepileptics (topiramate, valproate), antidepressants (amitriptyline, fluoxetine), CGRP monoclonal antibodies, and onabotulinumtoxinA 1, 4
• Preventive treatments typically reduce migraine frequency by 1-3 days per month compared to placebo 5

Special Considerations

Medication Overuse Headache

• Avoid overuse of acute headache medications (use >10 days per month) which can lead to medication overuse headache 4, 7
• Treatment requires detoxification and implementation of appropriate preventive therapy 1

When to Refer to a Specialist

• Cluster headaches 4
• Uncertain diagnosis 4
• Poor response to preventive strategies 4
• Migraine with persistent aura 4
• Headache with motor weakness 4

Patient Education

• Maintain a headache diary to track frequency, severity, triggers, and treatment response 4
• Identify and avoid personal triggers 4
• Establish regular sleep patterns and consider stress management techniques 4