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

Approach to Managing a Patient with Headache

Immediate Red Flag Screening

Begin by systematically screening for life-threatening secondary causes using specific red flag features that mandate urgent neuroimaging or emergency referral. 1

Critical red flags requiring immediate action include:

• Sudden-onset severe headache ("thunderclap") 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 (weakness, vision changes, speech difficulties, altered mental status) 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
• Headache awakening patient from sleep or worsened by Valsalva maneuver, cough, or positional changes suggests increased intracranial pressure from mass lesion or Chiari malformation 1, 2
• Progressive worsening pattern over days to weeks may indicate secondary headache disorder 1, 2
• Abnormal neurological examination warrants neuroimaging 1, 2

Diagnostic History Elements

If no red flags are present, obtain specific details to differentiate primary headache types using frequency, duration, location, character, and associated symptoms. 1

Frequency and Duration Classification

• Chronic migraine: ≥15 headache days per month for >3 months with ≥8 days having migraine features 3, 1, 2
• Episodic migraine: Individual attacks lasting 4-72 hours 1
• Cluster headache: 15-180 minutes per attack, with frequency of one to eight attacks daily during cluster periods 3, 1
• Tension-type headache: Variable duration 1

Location and Character

• Unilateral throbbing with moderate-to-severe intensity worsening with routine activity suggests migraine 3, 1
• Bilateral pressing/tightening with mild-to-moderate intensity not aggravated by routine activity suggests tension-type headache 3, 1
• Strictly unilateral orbital/supraorbital/temporal pain with ipsilateral autonomic symptoms (lacrimation, nasal congestion, rhinorrhea, ptosis, miosis, eyelid edema) suggests cluster headache 3, 1

Associated Symptoms

• Nausea/vomiting and photophobia/phonophobia support migraine diagnosis 3, 1
• Absence of nausea and photophobia/phonophobia supports tension-type headache 3

Medication Overuse Headache Assessment

Screen for medication overuse headache if patient uses acute medications >10 days per month, as this is a common cause of chronic daily headache. 1, 2

• Document all medications including nonprescription analgesics and substances obtained from others 4
• Opioids, butalbital-containing compounds, and benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal 4
• Patients overusing NSAIDs, acetaminophen, or triptans can usually withdraw more quickly 4
• Initiate preventive therapy immediately while detoxifying by withdrawing overused medications 1

Acute Treatment Based on Headache Type

Episodic Migraine

For mild-to-moderate attacks, use NSAIDs or acetaminophen with caffeine as first-line therapy; for moderate-to-severe attacks, use triptans. 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 angina 1, 6
• Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to first dose 6
• Consider administering first dose in medically supervised setting with ECG for high-risk patients 6
• Alternative acute treatments for patients with cardiovascular contraindications include gepants (rimegepant, ubrogepant) or lasmiditan (5-HT1F agonist) 5
• Triptans eliminate pain in 20-30% of patients by 2 hours but cause transient flushing, tightness, or tingling in upper body in 25% of patients 5

Cluster Headache

Acute treatment requires subcutaneous sumatriptan 6 mg and 100% oxygen at 12 L/min via non-rebreather mask. 1

• Prophylactic treatment includes verapamil 360 mg/day with ECG monitoring for PR interval prolongation 1

Prophylactic Therapy Indications

Offer prophylactic therapy if headaches occur more than twice weekly or if patient has chronic migraine. 1, 2

Chronic Migraine Prophylaxis (Mandatory)

• First-line options: Topiramate, onabotulinumtoxinA (FDA-approved for chronic migraine) 1, 2
• Alternative evidence-based options: Propranolol, timolol, amitriptyline, valproate, gabapentin 1, 2
• These medications reduce migraine frequency by 1-3 days per month relative to placebo 5

Common Pitfalls to Avoid

• Never use opioids or butalbital-containing compounds except as rare rescue medication, as they are most likely to cause medication-overuse headache and dependency 1, 4
• Avoid triptans in patients with cardiovascular disease due to vasoconstrictive properties causing coronary artery vasospasm, arrhythmias, and cerebrovascular events 6, 5
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 6

Patient Education and Monitoring

Instruct patients to maintain a headache diary tracking frequency, severity, triggers, and treatment response to guide ongoing management decisions. 1, 2

• Identify and avoid personal triggers 1, 2
• Establish regular sleep patterns to reduce migraine frequency 1, 2
• Address comorbid conditions including depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that impair treatment effectiveness 4
• Schedule regular follow-up to monitor progress and adjust therapy 4

Specialist Referral Indications

Refer to neurology or headache specialist for cluster headaches, uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with motor weakness. 2

• PCPs are essential for initial identification and appropriate referral, as well as managing patient care between specialist appointments 3