What is the initial management for a patient presenting with a headache?

Initial Management of Headache

Start with NSAIDs (ibuprofen, naproxen, or aspirin) as first-line treatment for most patients presenting with headache, unless red flags suggest a secondary cause requiring urgent evaluation. 1, 2

Immediate Assessment for Red Flags

Before initiating treatment, rapidly screen for secondary headache warning signs that require urgent imaging or specialist consultation 1:

• Thunderclap headache (sudden, severe onset) - suggests subarachnoid hemorrhage 1
• New headache in patients >50 years - consider temporal arteritis 1
• Progressive worsening headache - suggests intracranial mass lesion 1
• Headache with fever and neck stiffness - indicates possible meningitis 1
• Focal neurological deficits on examination - suggests structural lesion 1
• Headache worsened by Valsalva maneuver or awakening from sleep - suggests increased intracranial pressure 1
• Atypical aura symptoms - consider stroke or TIA 1

If any red flags are present, obtain neuroimaging (MRI preferred) before initiating symptomatic treatment. 1 If neurologic examination is completely normal and headache meets strict migraine criteria, imaging is not warranted. 1

First-Line Acute Treatment Algorithm

For Mild to Moderate Headache:

Use over-the-counter NSAIDs as initial therapy 1, 2, 3:

• Ibuprofen 400-800 mg 1
• Naproxen sodium 500-550 mg 1
• Aspirin 900-1000 mg 1
• Diclofenac potassium 50-100 mg 1, 2

Acetaminophen alone is ineffective for migraine and should only be used in patients intolerant of NSAIDs. 1 However, combination products containing aspirin + acetaminophen + caffeine have proven efficacy. 1, 2

Critical timing principle: Administer medication as early as possible in the attack - efficacy decreases significantly if delayed. 1, 2, 3

For Moderate to Severe Headache or NSAID Failure:

Escalate to triptans as second-line therapy 1, 2, 3:

• Oral options: sumatriptan 50-100 mg, rizatriptan 10 mg, zolmitriptan 2.5-5 mg, or naratriptan 2.5 mg 1, 4
• Most effective when taken early while headache is still mild 1, 2
• If one triptan fails, try a different triptan - failure of one does not predict failure of others 1, 3

Triptan contraindications (must screen before prescribing) 1:

• Uncontrolled hypertension
• Cardiovascular disease or risk factors
• Basilar or hemiplegic migraine
• Recent use of ergotamines or MAO inhibitors

For Headache with Prominent Nausea/Vomiting:

Use non-oral routes and add antiemetics 1, 2, 3:

• Intranasal sumatriptan 20 mg or subcutaneous sumatriptan 6 mg 1, 3, 4
• Add metoclopramide 10 mg IV/IM or prochlorperazine 10 mg IV/IM - these provide synergistic analgesia beyond just treating nausea 1, 3

Combination Therapy Strategy

For patients with inadequate response to monotherapy, combine triptan + NSAID 1, 2:

• This combination reduces relapse rates (return of headache within 48 hours) 1
• Example: sumatriptan 100 mg + naproxen sodium 500 mg 2

Critical Medication Overuse Warning

Limit acute medication use to prevent medication-overuse headache (MOH) 1, 2, 3:

• NSAIDs: ≤15 days per month 2
• Triptans: ≤10 days per month 2
• Any acute medication: no more than twice weekly 1

If patient uses acute medications >2 days/week, initiate preventive therapy immediately rather than increasing acute medication frequency. 1, 2

Medications to Avoid

Never use opioids or butalbital-containing compounds for routine headache management 1, 2, 3:

• Questionable efficacy for migraine 1
• High risk of dependency and medication-overuse headache 1
• Worsen long-term outcomes 1

Avoid ergot alkaloids - poorly effective and potentially toxic compared to triptans. 1, 2

When to Consider Preventive Therapy

Initiate preventive treatment if any of the following apply 1, 2:

• ≥2 migraine attacks per month causing ≥3 days of disability
• Using acute medications >2 days per week
• Contraindications to or failure of all acute treatments
• Uncommon migraine variants (hemiplegic, prolonged aura, migrainous infarction)

First-line preventive agents 1:

• Propranolol 80-240 mg daily
• Timolol 20-30 mg daily
• Amitriptyline 30-150 mg daily
• Divalproex sodium 500-1500 mg daily

Common Pitfalls to Avoid

• Delaying triptan administration until headache is severe - triptans work best when taken early 1, 2
• Abandoning a triptan after single failure - try different triptans before declaring class failure 1, 3
• Allowing escalating acute medication use without transitioning to preventive therapy - creates MOH cycle 1, 2
• Using acetaminophen monotherapy for migraine - ineffective 1
• Prescribing triptans without screening cardiovascular contraindications 1