Management of Acute Headache
Begin by immediately ruling out life-threatening secondary causes through targeted history and examination for red flags, then classify as primary versus secondary headache, and treat accordingly with evidence-based pharmacotherapy tailored to headache type and severity. 1, 2
Initial Assessment: Red Flags Requiring Urgent Investigation
The cornerstone is identifying patients who need immediate neuroimaging or further workup versus those with benign primary headache 3, 4:
Red Flags Mandating Urgent Evaluation
- Thunderclap onset (pain peaking within 1 second to 1 minute) - consider subarachnoid hemorrhage 1, 5
- Abrupt onset of severe headache - highest risk feature 1
- Rapidly increasing frequency of headaches 1
- Headache awakening patient from sleep 1
- Focal neurologic signs or symptoms 1
- History of uncoordination 1
- Marked change in headache pattern 1
- Persistent headache following head trauma 1
- Headache worsened by Valsalva maneuver 1
- New onset in patient >40-50 years old 1, 5
- Fever with neck stiffness (meningitis) 2, 6
- Presence of meningism, witnessed loss of consciousness, or limited neck flexion on exam 5
Neuroimaging Indications
Obtain CT head immediately if any red flags present; neuroimaging is NOT warranted for patients with normal neurologic examination and typical primary headache features meeting strict diagnostic criteria. 1
- Consider neuroimaging for unexplained abnormal neurologic findings 1
- If CT negative but subarachnoid hemorrhage suspected, proceed to lumbar puncture 7, 6
Classification of Primary Headaches
Once secondary causes excluded, classify using International Headache Society criteria 1:
Migraine Diagnostic Features (Need ≥2 of following)
- Unilateral location 1
- Throbbing character 1
- Moderate to severe intensity 1
- Worsening with routine activity 1
PLUS ≥1 of:
Tension-Type Headache Features (Need ≥2 of following)
- Pressing, tightening, or nonpulsatile character 1
- Mild to moderate intensity 1
- Bilateral location 1
- No aggravation with routine activity 1
- No nausea/vomiting and no photophobia/phonophobia together (may have one) 1
Cluster Headache Features
- Severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes 1
- Ipsilateral autonomic features: lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema 1
- Frequency of 1-8 attacks per day 1
Treatment Algorithm by Headache Type and Severity
Mild to Moderate Migraine (First-Line)
Start with NSAIDs as first-line therapy, administered as early as possible during the attack. 1, 2
- Naproxen sodium 500-825 mg at onset, repeat every 2-6 hours as needed (max 1.5g/day) 2
- Ibuprofen 400-800 mg 2
- Aspirin 900-1000 mg 2
- Combination: aspirin + acetaminophen + caffeine (particularly effective) 1, 2
Add antiemetic 20-30 minutes before NSAID for synergistic analgesia: 2
Moderate to Severe Migraine (First-Line)
Triptans are first-line for moderate-to-severe attacks or when NSAIDs fail. 2
Oral triptans with strong evidence: 2
- Sumatriptan 50-100 mg
- Rizatriptan 10 mg
- Naratriptan 2.5 mg
- Zolmitriptan 2.5-5 mg
For rapid onset or when nausea/vomiting present: 2
- Subcutaneous sumatriptan 6 mg - most effective route, 59% pain-free at 2 hours, onset within 15 minutes 2
- Intranasal sumatriptan 5-20 mg 2
Severe Migraine Requiring Parenteral Therapy
For ED/urgent care presentation, use IV combination therapy as first-line. 2
Recommended IV "Migraine Cocktail": 2
- Metoclopramide 10 mg IV (provides direct analgesia, not just antiemetic effect) 2
- Ketorolac 30 mg IV (60 mg IM if <65 years, reduce dose if ≥65 or renal impairment) 2
Alternative IV options: 2
- Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, fewer side effects than chlorpromazine) 2
- Dihydroergotamine (DHE) IV - good evidence for efficacy and safety 2
Avoid in severe migraine: 1, 2
- Opioids (meperidine, hydromorphone) - lead to dependency, rebound headaches, loss of efficacy 1, 2
- Reserve opioids only when all other options contraindicated and abuse risk addressed 2
Status Migrainosus (>72 hours)
- Consider corticosteroids (though limited evidence for routine acute use) 2, 7
- IV DHE protocols 2
- Admit for IV therapy if outpatient management fails 7
Critical Medication-Overuse Headache Prevention
Limit ALL acute headache medications to no more than 2 days per week (twice weekly) to prevent medication-overuse headache. 1, 2
- Frequent use (>2 days/week) of NSAIDs, triptans, ergotamines, opioids, or analgesics causes rebound headaches 1, 2
- If patient requires acute treatment >2 days/week, initiate preventive therapy 2
When Current Medication Stops Working
First try a different triptan - failure of one does not predict failure of others. 2
Escalation Algorithm:
- Ensure early administration - triptans most effective when taken while pain still mild 2
- Add fast-acting NSAID to prevent 48-hour recurrence (occurs in 40% of patients) 2
- Change route - try subcutaneous if oral fails, especially if rapid peak intensity or vomiting 2
- Rule out medication-overuse headache if using acute meds >2 days/week 2
- Initiate preventive therapy if headaches impair quality of life despite optimized acute treatment 2
Do NOT allow patients to increase frequency of acute medication use - this creates vicious cycle of medication-overuse headache. 2
Contraindications and Cautions
Triptans - Avoid in:
- Ischemic heart disease or previous MI 2
- Uncontrolled hypertension 2
- Significant cardiovascular disease 2
NSAIDs - Avoid in:
Metoclopramide - Contraindicated in:
Prochlorperazine - Additional risks:
- Tardive dyskinesia 2
- Hypotension, tachycardia, arrhythmias 2
- Contraindicated with CNS depression or adrenergic blockers 2
Disposition and Follow-Up
Refer all primary headache patients to Headache Center/neurology for long-term management - lack of referral results in high relapse rates and repeat ED visits. 7, 3