What is the appropriate management for a patient presenting with a headache?

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:

• Nausea and/or vomiting 1
• Photophobia and phonophobia 1

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

• Metoclopramide 10 mg PO 2
• Prochlorperazine 25 mg PO 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 presentations, 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 (or 60 mg IM if <65 years) - rapid onset, 6-hour duration, minimal rebound risk 1, 2
• Prochlorperazine 10 mg IV - comparable efficacy to metoclopramide 2

Alternative parenteral options: 2

• Dihydroergotamine (DHE) IV or intranasal - good efficacy and safety profile 2

Avoid in acute migraine management: 1, 2

• Opioids (hydromorphone, meperidine) - lead to dependency, rebound headaches, loss of efficacy 1, 2
• Prednisone/corticosteroids - limited evidence for acute treatment, more appropriate for status migrainosus 2
• Diphenhydramine - not evidence-based for migraine 2

Tension-Type Headache Treatment

NSAIDs or acetaminophen are appropriate for tension-type headache. 1

• Ibuprofen 400-600 mg 1
• Naproxen 500 mg 1
• Acetaminophen 1000 mg 1

Cluster Headache Treatment

Cluster headache requires specific rapid-acting therapy. 1

• Subcutaneous sumatriptan 6 mg - most effective 2
• High-flow oxygen 100% at 12-15 L/min for 15-20 minutes (standard of care, though not detailed in provided evidence)

Critical Medication-Overuse Headache Prevention

Limit ALL acute headache medications to no more than 2 days per week (or twice weekly) to prevent medication-overuse headache. 1, 2

Medications with High Rebound Risk

• Opioids 1
• Ergotamine 1
• Triptans (when overused) 1
• Analgesics (when overused) 1
• Caffeine-containing combinations 2

If patient requires acute treatment >2 days/week, initiate preventive therapy immediately. 2

When Current Treatment Fails

If established migraine treatment stops working, follow this escalation algorithm: 2

1. Rule out medication-overuse headache - most common cause of treatment failure 2
2. Try different triptan - failure of one doesn't predict failure of others 2
3. Optimize timing - ensure early administration while pain still mild 2
4. Add combination therapy - triptan + fast-acting NSAID prevents 40% recurrence rate 2
5. Change route - switch to subcutaneous if oral fails 2
6. Initiate preventive therapy if using acute meds >2 days/week 2

Common Pitfalls to Avoid

• Do NOT increase frequency of acute medications in response to treatment failure - this creates medication-overuse headache cycle 2
• Do NOT use opioids as first-line - poor efficacy, high dependency risk 1, 2
• Do NOT skip antiemetics - nausea itself is disabling and warrants treatment even without vomiting 2
• Do NOT delay neuroimaging when red flags present - missing subarachnoid hemorrhage or meningitis has dire consequences 7, 5
• Do NOT forget to refer to headache specialist after ED visit - lack of referral leads to high relapse and re-presentation rates 7

Contraindications and Cautions

Triptans contraindicated in: 2

• Ischemic heart disease or previous MI
• Uncontrolled hypertension
• Significant cardiovascular disease

Ketorolac use with caution in: 2

• Renal impairment (CrCl <30 mL/min)
• History of GI bleeding
• Heart disease

Metoclopramide contraindicated in: 2

• Pheochromocytoma
• Seizure disorder
• GI bleeding or obstruction

Prochlorperazine additional risks: 2

• Tardive dyskinesia
• Hypotension, tachycardia, arrhythmias
• Contraindicated with CNS depression or adrenergic blockers