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

Headache Management Approach

Begin by immediately screening for red flag features that indicate life-threatening secondary causes requiring urgent neuroimaging or emergency referral, then differentiate primary headache types based on specific clinical characteristics to guide targeted treatment. 1

Initial Red Flag Assessment

Screen every headache patient for the following red flags that mandate urgent evaluation:

• 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 mandate immediate neuroimaging with MRI preferred over CT 1
• 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 1, 2
• Fever or signs of infection require consideration of meningitis or encephalitis with urgent lumbar puncture 1, 2
• Headache worsened by Valsalva, cough, or positional changes suggests increased intracranial pressure from mass lesion or Chiari malformation 1, 2
• Headache awakening patient from sleep warrants further investigation 1, 2
• Progressive worsening pattern may indicate secondary headache disorder 2
• Abnormal neurological examination requires neuroimaging 2

If no red flags are present, proceed to differentiate primary headache types. 3

Diagnostic History Elements for Primary Headache

Obtain specific details to differentiate primary headache types:

• Frequency and duration: Chronic migraine is defined as ≥15 headache days per month for >3 months with ≥8 days having migraine features 1, 2
• Location and character: Unilateral throbbing suggests migraine; bilateral pressing/tightening suggests tension-type; strictly unilateral with autonomic symptoms suggests cluster headache 1, 4
• Duration of individual attacks: Migraine lasts 4-72 hours, cluster headache lasts 15-180 minutes, tension-type is variable 1
• Associated symptoms: Migraine typically includes nausea/vomiting and photophobia/phonophobia; tension-type lacks these features; cluster headache has ipsilateral autonomic symptoms like lacrimation and nasal congestion 1, 4
• Aggravating factors: Migraine worsens with activity; tension-type does not 4

Use a headache diary to track frequency, severity, triggers, and treatment response, as patients often cannot accurately report headache frequency without documentation. 3, 2

Management Based on Headache Type

Episodic Migraine (Acute Treatment)

• For mild-to-moderate attacks: Use NSAIDs or acetaminophen with caffeine as first-line therapy 1, 5
• For moderate-to-severe attacks: Use triptans, which eliminate pain in 20-30% of patients by 2 hours 1, 5
  • Screen for cardiovascular disease before prescribing triptans, as they are contraindicated in coronary artery disease, uncontrolled hypertension, stroke history, Wolff-Parkinson-White syndrome, and Prinzmetal's variant angina 6
  • Triptans cause transient flushing, tightness, or tingling in the upper body in 25% of patients 5
• Alternative acute treatments: Gepants (rimegepant or ubrogepant) eliminate headache in 20% of patients at 2 hours with adverse effects of nausea and dry mouth in 1-4%; lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 5

Chronic Migraine (Prophylactic Treatment)

Prophylactic therapy is mandatory for chronic migraine. 3

• OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis and reduces headache days and severity 3, 2
• Topiramate is the only oral agent with proven efficacy in randomized, placebo-controlled trials specifically for chronic migraine 3
• Other evidence-based options include propranolol, timolol, amitriptyline, valproate, and gabapentin, though these have evidence primarily in episodic migraine 3, 1, 2
• Preventive treatments reduce migraine by 1-3 days per month relative to placebo 5

Initiate prophylaxis if headaches occur more than twice weekly. 2

Cluster Headache

• Acute treatment: Subcutaneous sumatriptan 6 mg and 100% oxygen at 12 L/min via non-rebreather mask 1
• Prophylactic treatment: Verapamil 360 mg/day with ECG monitoring for PR interval prolongation 1

Tension-Type Headache

• Acute treatment: NSAIDs 7
• Prophylactic treatment: Tricyclic antidepressants 7

Medication-Overuse Headache Management

Diagnose medication-overuse headache if patient uses acute medications >10 days per month. 1, 2

• Immediately initiate preventive therapy while detoxifying by withdrawing overused medications 1
• Avoid opioids or butalbital-containing compounds except as rare rescue medication, as they are most likely to cause medication-overuse headache 1, 2
• Overuse of acute migraine drugs (ergotamine, triptans, opioids) for ≥10 days per month leads to exacerbation of headache 6
• Detoxification includes withdrawal of overused drugs and treatment of withdrawal symptoms, which often includes transient worsening of headache 6

Referral Indications

Refer to a neurologist for:

• Cluster headaches 8
• Uncertain diagnosis 8
• Poor response to preventive strategies 8
• Migraine with persistent aura 8
• Headache with motor weakness 8

Patient Education Requirements

• Maintain a headache diary to guide management decisions 1, 2
• Identify and avoid personal triggers 1, 2
• Establish regular sleep patterns to reduce migraine frequency 1, 2
• Understand proper medication use to avoid rebound headaches 2

Common Pitfalls

• Failing to screen for red flags before attributing headache to primary disorder 1
• Prescribing triptans without cardiovascular screening 6
• Missing medication-overuse headache in patients on long-term analgesics 8
• Treating cerebrovascular events as migraine when symptoms are actually stroke or hemorrhage 6
• Failing to initiate prophylactic therapy in chronic migraine patients 3