Management of New Onset Headaches with Irritability
New onset headaches with irritability require immediate evaluation for secondary causes—particularly subarachnoid hemorrhage, meningitis, intracranial mass, or temporal arteritis—before considering primary headache treatment. 1, 2
Immediate Red Flag Assessment
The combination of new onset headache with irritability (altered personality/behavior) is a red flag that mandates urgent evaluation for secondary causes. 1, 3
Critical red flags requiring emergency imaging:
- New onset in patients >50 years old (consider temporal arteritis, mass lesion, subdural hematoma) 1, 4
- Progressive worsening of headache (suggests space-occupying lesion) 1, 3
- Altered consciousness, memory changes, or personality changes (suggests intracranial pathology) 1, 3
- Thunderclap onset (subarachnoid hemorrhage until proven otherwise) 1, 2
- Headache with fever or neck stiffness (meningitis) 1
- Focal neurological symptoms or unexplained neurological findings on examination 1, 3
Diagnostic Workup Algorithm
Step 1: Obtain urgent non-contrast head CT immediately if any red flags are present, particularly thunderclap onset, neurological deficits, or altered mental status. 2, 3
Step 2: If CT is negative but high suspicion remains (especially for subarachnoid hemorrhage presenting >6 hours from onset), proceed to lumbar puncture with spectrophotometric analysis for xanthochromia. 2, 4
Step 3: Consider MRI brain as the diagnostic test of choice for most non-emergent presentations with new onset headache and irritability, as it has superior sensitivity for detecting masses, inflammation, and vascular abnormalities. 3, 4
Step 4: In patients >50 years, obtain erythrocyte sedimentation rate and C-reactive protein to evaluate for temporal arteritis, though recognize that ESR can be normal in 10-36% of temporal arteritis cases. 4
Common Pitfalls to Avoid
- Do not assume benign primary headache without imaging when irritability or personality changes are present—these behavioral symptoms suggest intracranial pathology. 1, 2
- Do not rely on normal neurological examination alone—the yield of neuroimaging in patients with normal exams is low (0.8% brain tumors, 1.2% strokes) but not zero, and red flag features override reassuring exam findings. 4
- Do not miss temporal arteritis in older patients—headache is the most common symptom (60-90% of cases), and delayed diagnosis risks permanent vision loss. 4
Treatment After Secondary Causes Excluded
Only after secondary causes have been appropriately evaluated should acute migraine treatment be initiated:
For moderate to severe headache:
- First-line: Combination of triptan (sumatriptan, rizatriptan, eletriptan, or zolmitriptan) plus NSAID (ibuprofen 400-800mg or naproxen 275-550mg) 1
- Alternative first-line: Aspirin-acetaminophen-caffeine combination 1
For mild to moderate headache:
- NSAIDs alone (ibuprofen, naproxen, or aspirin) 1
- Acetaminophen combined with NSAID if NSAIDs alone insufficient 1
If nausea/vomiting present:
- Add metoclopramide or prochlorperazine as adjunctive antiemetic 1
- Consider non-oral triptan formulation (subcutaneous sumatriptan, intranasal zolmitriptan) 1
Medications to avoid:
- Do not use opioids or butalbital-containing compounds—these lead to dependency, medication overuse headache, and loss of efficacy. 1
Counsel patients to:
- Begin treatment as soon as possible after headache onset for maximum efficacy 1
- Avoid medication overuse (≥15 days/month for NSAIDs/acetaminophen, ≥10 days/month for triptans) to prevent medication overuse headache 1
- Return immediately for worsening symptoms, new neurological signs, or persistent headache beyond 24 hours 2
When to Consider Preventive Therapy
If headaches continue to impair quality of life on ≥2 days per month despite optimized acute treatment, initiate preventive therapy with options including candesartan, propranolol, topiramate, or CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab). 1, 5