What is the approach to managing a patient presenting with a headache?

Approach to Managing a Patient with Headache

Begin by immediately screening for "red flag" features that indicate potentially life-threatening secondary causes requiring urgent neuroimaging or emergency referral, including sudden-onset severe headache ("thunderclap"), headache awakening the patient from sleep, fever or signs of infection, new neurological deficits, age over 50 years with new-onset headache, headache worsened by Valsalva maneuver, progressive worsening pattern, or abnormal neurological examination. 1, 2

Initial Red Flag Assessment

Critical warning signs requiring immediate action:

• Sudden-onset severe headache reaching maximal intensity immediately suggests subarachnoid hemorrhage and requires non-contrast head CT within 6 hours, followed by lumbar puncture if CT is negative 1
• New neurological deficits (focal weakness, visual changes, altered mental status) mandate immediate neuroimaging with MRI preferred over CT 2
• Age >50 years with new-onset headache increases risk of temporal arteritis, subdural hematoma, or neoplasm to 15% and warrants ESR/CRP testing and neuroimaging 2, 3
• Fever or signs of infection require consideration of meningitis or encephalitis with urgent lumbar puncture 2
• Headache worsened by Valsalva, cough, or positional changes suggests increased intracranial pressure from mass lesion or Chiari malformation 2

Diagnostic History Elements

For patients without red flags, obtain specific details to differentiate primary headache types:

• Frequency and duration: Chronic migraine is ≥15 headache days per month for >3 months with ≥8 days having migraine features 1
• Location: Unilateral throbbing suggests migraine; bilateral pressing/tightening suggests tension-type; strictly unilateral with autonomic symptoms suggests cluster headache 4, 5
• Duration of individual attacks: Migraine lasts 4-72 hours; cluster headache lasts 15-180 minutes; tension-type is variable 4, 5
• Associated symptoms: Nausea, vomiting, photophobia, and phonophobia indicate migraine; ipsilateral lacrimation, rhinorrhea, or ptosis indicate cluster headache 4, 5
• Aura presence: Visual, sensory, or speech disturbances preceding headache by 5-60 minutes confirm migraine with aura 5
• Current medication use: Document frequency of acute medication use, as use >2 days per week risks medication-overuse headache 1, 2

Neuroimaging Decision Algorithm

Neuroimaging is indicated when:

• Any red flag features are present (as listed above) 2
• Unexplained abnormal neurological examination findings 2
• Atypical features that don't fit established primary headache patterns 2
• Progressive worsening despite appropriate treatment 2

Neuroimaging is NOT routinely indicated when:

• Normal neurological examination 2
• Features consistent with primary headache disorders 2
• Long history of similar headaches without pattern change 2

The yield of neuroimaging in patients with normal examination and typical primary headache is extremely low: brain tumors 0.8%, arteriovenous malformations 0.2%, aneurysms 0.1%. 3

Management Based on Headache Type

For Episodic Migraine (Acute Treatment)

First-line acute therapy options:

• NSAIDs or acetaminophen with caffeine for mild-to-moderate attacks 5
• Triptans (e.g., sumatriptan 50-100 mg) eliminate pain in 20-30% at 2 hours for moderate-to-severe attacks, but screen for cardiovascular disease first as they are contraindicated in coronary artery disease, uncontrolled hypertension, and stroke history 6, 5
• Gepants (rimegepant, ubrogepant) eliminate headache in 20% at 2 hours and are safe in cardiovascular disease 5
• Lasmiditan is safe in patients with cardiovascular risk factors 5

Critical pitfall: Limit acute medication use to ≤2 days per week to prevent medication-overuse headache, which causes increasing headache frequency progressing to daily headaches. 1, 6

For Chronic Migraine (≥15 Headache Days/Month)

Prophylactic therapy is mandatory and should include:

• Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 1
• OnabotulinumtoxinA is FDA-approved specifically for chronic migraine prophylaxis 2
• Other options with evidence in episodic migraine include propranolol, timolol, amitriptyline, valproate, gabapentin 1, 2

Indications for preventive therapy:

• ≥2 attacks per month producing disability lasting ≥3 days 1
• Use of abortive medication >2 times per week 1
• Contraindication to or failure of acute treatments 1
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 1

For Cluster Headache

Acute treatment (both first-line with Level 1 evidence):

• Subcutaneous sumatriptan 6 mg provides relief in 70% within 10 minutes 4
• 100% oxygen at 12 L/min via non-rebreather mask has equal efficacy to sumatriptan 4
• Screen for cardiovascular disease before prescribing sumatriptan (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history of CAD) 4

Prophylactic treatment:

• Verapamil 360 mg/day is first-line prophylaxis with ECG monitoring for PR interval prolongation 4
• Consider oral corticosteroids or greater occipital nerve blockade as bridging therapy while verapamil takes effect 4

Medication-Overuse Headache Management

If patient uses acute medications >10 days per month (or triptans/opioids/combination analgesics >10 days per month):

• Diagnose medication-overuse headache which presents as daily or near-daily headaches 1, 6
• Initiate preventive therapy immediately 1
• Detoxify by withdrawing overused medications with warning that headache will transiently worsen during withdrawal 6
• Avoid prescribing opioids or butalbital-containing compounds except as rare rescue medication, as these are most likely to cause medication-overuse headache 1, 2

Referral to Neurology

Refer to neurologist when:

• Cluster headache diagnosis 2, 7
• Uncertain diagnosis after initial evaluation 2, 7
• Poor response to preventive strategies 2, 7
• Migraine with persistent aura 2, 7
• Headache with motor weakness 2, 7
• Suspected medication-overuse headache requiring detoxification 7

Patient Education Requirements

• Maintain headache diary documenting frequency, severity, triggers, medication use, and treatment response to guide management decisions 2
• Identify and avoid personal triggers including irregular sleep, stress, specific foods, alcohol 2
• Establish regular sleep patterns as sleep disruption is a common migraine trigger 2