Frequent Headaches in a 29-Year-Old Woman
Your daughter most likely has migraine, which is the most common cause of recurrent disabling headaches in young adults, particularly women, and requires both accurate diagnosis and consideration of preventive therapy given her frequency of several episodes per week. 1
Initial Diagnostic Approach
The first priority is determining whether these are primary headaches (migraine or tension-type) versus secondary headaches requiring urgent evaluation. 1
Key History Elements to Obtain
Ask your daughter about these specific features 1:
- Headache characteristics: Duration (migraines last 4-72 hours), location (unilateral suggests migraine), quality (pulsating/throbbing suggests migraine vs. pressing/tightening suggests tension-type), and intensity 1
- Associated symptoms: Nausea, vomiting, photophobia (light sensitivity), phonophobia (sound sensitivity) all point toward migraine 1
- Aura symptoms: Visual disturbances, sensory changes, or speech difficulties that develop gradually over ≥5 minutes before headache onset indicate migraine with aura 1
- Triggers: Stress, certain foods, hormonal changes (menstruation), sleep changes, weather 2
- Medication use: Frequency of pain medication use is critical—overuse causes medication overuse headache 2
Red Flags Requiring Urgent Evaluation
She needs immediate medical evaluation if any of these are present 1, 3:
- Sudden onset "thunderclap" headache (worst headache of life)
- New headache after age 50 (not applicable here)
- Progressively worsening pattern
- Headache awakening her from sleep
- Headache worsened by coughing, straining, or Valsalva maneuver
- Any abnormal neurological symptoms or examination findings
Most Likely Diagnosis: Migraine
If she has at least 5 attacks with at least two of these features: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine activity—PLUS at least one of nausea/vomiting or photophobia and phonophobia—she meets criteria for migraine without aura. 1
Migraine is significantly more common in women of reproductive age and is the second leading cause of disability worldwide. 2
Medication Overuse Headache Risk
With headaches occurring several times per week, assess immediately for medication overuse headache, which develops from regular overuse of acute headache medications and creates a vicious cycle. 2
High-risk factors in order of importance 2:
- Headache frequency ≥7 days per month
- Migraine diagnosis
- Frequent use of analgesics (even over-the-counter), anxiolytics, or sedatives
- History of anxiety or depression
- Physical inactivity
If she's taking pain medication (including ibuprofen, acetaminophen, triptans, or combination products) more than 10-15 days per month, medication overuse headache should be suspected. 2
Treatment Strategy
For Acute Attacks
For mild-to-moderate migraine attacks, use NSAIDs (like ibuprofen 400mg), acetaminophen (1000mg), or aspirin-acetaminophen-caffeine combinations. 2, 1
For moderate-to-severe attacks, triptans or the newer CGRP receptor antagonists (gepants like ubrogepant or rimegepant) are appropriate options. 2
Preventive Therapy Indication
Because she has headaches several times per week (≥2 headaches per week), she is a candidate for preventive therapy, which aims to reduce headache frequency, severity, and disability. 1
First-Line Preventive Options
Based on the most recent 2024 VA/DoD guidelines, evidence-based preventive medications include 2:
Strong recommendations (highest quality evidence):
- Candesartan or telmisartan (angiotensin receptor blockers): 16-32mg daily 2
- CGRP monoclonal antibodies (erenumab 70-140mg monthly subcutaneous, fremanezumab 225mg monthly or 675mg quarterly subcutaneous, galcanezumab): These have strong evidence for both episodic and chronic migraine 2
Reasonable alternatives with good evidence:
- Topiramate 50-100mg daily (also effective for chronic migraine) 2
- Propranolol (beta-blocker) 2
- Lisinopril (ACE inhibitor) 2
- Magnesium (oral supplementation) 2
- Valproate 600-1500mg daily—but absolutely contraindicated in women of childbearing potential due to teratogenicity 2
The choice depends on comorbidities (hypertension favors candesartan/lisinopril, anxiety/depression might favor amitriptyline as second-line), contraindications, cost, and patient preference. 2
Non-Pharmacologic Approaches
Physical therapy and aerobic exercise are recommended for migraine management and should be incorporated regardless of medication choices. 2
Common Pitfalls to Avoid
Missing medication overuse headache: This transforms episodic headaches into chronic daily headaches and requires withdrawal of the overused medication (abrupt withdrawal preferred except for opioids) 2
Not offering preventive therapy: Many patients with frequent headaches continue suffering with only acute treatments when preventive therapy could significantly improve quality of life 1
Using valproate in women of childbearing age: This is absolutely contraindicated due to severe teratogenic effects 2
Inadequate follow-up: Response to preventive therapy should be evaluated within 2-3 months, measuring headache frequency, severity, and disability 2
Recommended Next Steps
She should see a healthcare provider who will:
- Take a detailed headache history using the elements above
- Perform a neurological examination
- Consider having her keep a headache diary for 1 month to document frequency, triggers, and medication use 2, 4
- Initiate preventive therapy if she has ≥2 headaches per week
- Screen for and address comorbidities like anxiety, depression, or sleep disturbances 2
Neuroimaging (MRI preferred over CT) is NOT routinely needed for typical recurrent headaches with normal neurological examination, but IS indicated if any red flag features are present. 1