What is the approach to evaluating and managing severe headache?

Evaluation and Management of Severe Headache

For severe headache presenting to acute care, immediately rule out life-threatening secondary causes using red flag criteria, then treat presumed migraine with IV metoclopramide 10mg plus IV ketorolac 30mg as first-line therapy, avoiding opioids entirely. 1

Initial Evaluation: Red Flag Assessment

The first priority is identifying secondary headaches requiring urgent intervention. Screen systematically for these red flags 2, 3:

Immediate emergency evaluation required for:

• Thunderclap headache (sudden, severe onset reaching maximum intensity within seconds to minutes) 3
• Fever with meningeal signs (neck stiffness, photophobia) 3
• Focal neurologic deficits or altered consciousness 2, 3
• Papilledema on fundoscopic examination 3
• New headache in patients >50 years old 4
• Headache in immunocompromised or cancer patients 4
• Headache awakening patient from sleep 2
• Progressive worsening or change in established headache pattern 2
• Headache following head trauma 2

Neuroimaging indications:

• Non-contrast CT head is first-line for suspected subarachnoid hemorrhage, intracranial hemorrhage, or mass effect 3
• If CT is negative but subarachnoid hemorrhage suspected, lumbar puncture is mandatory 3
• MRI brain is preferred for non-emergent evaluation when secondary causes suspected 2, 3
• Do not obtain neuroimaging for typical primary headache without red flags or abnormal neurologic examination 2

History Taking for Primary Headache Diagnosis

Once secondary causes excluded, obtain these specific details 2:

Essential headache characteristics:

• Frequency (days per month with headache) 2
• Duration of individual episodes 2
• Pain location (unilateral vs bilateral) 2
• Pain quality (throbbing vs pressing/tightening) 2
• Pain intensity (mild, moderate, severe) 2
• Aggravation by routine physical activity 2

Associated symptoms:

• Nausea and/or vomiting 2
• Photophobia and phonophobia 2
• Visual or sensory aura symptoms (duration, characteristics) 2
• Autonomic features (lacrimation, nasal congestion, ptosis, miosis) 2

Medication history:

• Current acute medication use (frequency per week/month) 2
• Response to previous treatments 2
• Risk assessment for medication-overuse headache (≥15 days/month simple analgesics or ≥10 days/month triptans/combination analgesics for >3 months) 2

Family history of migraine strengthens diagnosis 2

Acute Treatment Algorithm for Severe Headache

First-Line IV Treatment (Emergency/Urgent Care Setting)

The most effective combination is IV metoclopramide 10mg plus IV ketorolac 30mg 1. This provides:

• Rapid pain relief from ketorolac (NSAID with 6-hour duration) 1
• Synergistic analgesia from metoclopramide (not just antiemetic effect) 1
• Minimal risk of rebound headache 1

Alternative IV monotherapy options:

• Prochlorperazine 10mg IV (comparable efficacy to metoclopramide, fewer extrapyramidal side effects than chlorpromazine) 1
• Ketorolac 30-60mg IV/IM alone (reduce dose to 15-30mg in patients ≥65 years or with renal impairment) 1

Avoid these medications:

• Never use opioids (hydromorphone, morphine, oxycodone) as they cause dependency, rebound headaches, and loss of efficacy 1, 5
• Avoid butalbital-containing compounds for same reasons 6, 5
• Prednisone/corticosteroids have limited evidence for acute treatment (reserved for status migrainosus) 1
• Diphenhydramine adds no benefit and causes sedation 1

Oral Treatment for Moderate-Severe Headache

For patients who can tolerate oral medications:

• NSAIDs first-line: ibuprofen, naproxen sodium, aspirin, or diclofenac potassium 6, 1
• Add triptan if NSAID inadequate: sumatriptan, rizatriptan, naratriptan, or zolmitriptan 1
• Triptans most effective when taken early while headache still mild 6
• Combination aspirin + acetaminophen + caffeine for moderate-severe attacks 1

For patients with severe nausea/vomiting:

• Subcutaneous sumatriptan 6mg (highest efficacy: 59% pain-free at 2 hours) 1
• Intranasal sumatriptan 5-20mg 1
• Add oral metoclopramide or domperidone as adjunct 2

Critical Pitfall: Medication-Overuse Headache

Limit acute medication use to ≤2 days per week 2, 1. Using acute treatments more frequently causes:

• Transformation to chronic daily headache 2
• Loss of treatment responsiveness 1
• Requires 3-month withdrawal period for resolution 2

If patient already using acute medications >2 days/week, initiate preventive therapy immediately 2

When to Initiate Preventive Therapy

Start preventive treatment when 2:

• Headaches impair quality of life on ≥2 days per month despite optimized acute therapy 2
• Patient using acute medications >2 days per week 2
• Attacks are prolonged or particularly severe 2

First-line preventive options:

• Beta-blockers: propranolol, metoprolol, atenolol, or bisoprolol 2
• Topiramate 2
• Candesartan 2

Second-line options:

• Amitriptyline 2
• Flunarizine 2
• Avoid sodium valproate in women of childbearing potential (absolutely contraindicated) 2

Assess preventive efficacy after 2-3 months for oral agents, 3-6 months for CGRP monoclonal antibodies 2

Specialist Referral Indications

Refer to neurology/headache specialist when 2:

• Diagnostic uncertainty despite thorough evaluation 2
• Failure of multiple preventive therapies with adequate trials 2
• Complicated by significant comorbidities 2
• Persistent aura or aura with motor weakness 7
• Cluster headache diagnosis 7
• Medication-overuse headache not responding to withdrawal 7

Approximately 90% of migraine patients should be managed successfully in primary care 2

Patient Education Essentials

Set realistic expectations 2:

• Goal is control, not cure—reducing attack frequency, duration, and disability 2
• Effective treatment allows continuation of life activities with minimal hindrance 2

Lifestyle modifications 6, 5:

• Maintain adequate hydration 6, 5
• Regular meals (avoid skipping) 6, 5
• Consistent sleep schedule (7-9 hours) 6, 5
• Regular physical activity 6, 5
• Stress management techniques 6, 5

Headache diary use:

• Record daily headache occurrence, intensity, associated symptoms, and medication use 2
• Essential for monitoring treatment response and identifying medication overuse 2