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, then treat primary headaches with NSAIDs or triptans based on severity, while avoiding opioids and limiting acute medication use to prevent medication-overuse headache. 1

Initial Assessment: Rule Out Red Flags

The cornerstone is identifying "red flags" that mandate urgent neuroimaging or further investigation 1:

• Thunderclap onset (pain peaking within seconds to 1 minute) 2
• Rapidly increasing frequency of headaches 1
• Focal neurologic signs or symptoms 1
• Headache awakening patient from sleep 1
• Abrupt onset of severe headache 1
• Marked change in headache pattern 1
• Persistent headache following head trauma 1
• Age ≥40 years with new-onset headache 2
• Neck pain/stiffness or meningismus 2
• Witnessed loss of consciousness 2
• Onset during exertion 2

If any red flags are present, obtain neuroimaging (CT scan) immediately. 1 If CT is negative but subarachnoid hemorrhage is still suspected, perform lumbar puncture. 1

Classification of Primary Headaches

Once secondary causes are excluded, classify the headache type 1:

Migraine Diagnostic Criteria:

• At least 2 of: unilateral location, throbbing character, worsening with routine activity, moderate-to-severe intensity 1
• At least 1 of: nausea/vomiting OR photophobia and phonophobia 1

Tension-Type Headache:

• Pressing/tightening (non-pulsatile) character, mild-to-moderate intensity, bilateral location 1
• No nausea/vomiting and no photophobia with phonophobia 1

Cluster Headache:

• Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes 1
• Ipsilateral autonomic features: lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema 1

Treatment Algorithm Based on Severity

Mild-to-Moderate Migraine (First-Line):

Start with NSAIDs as first-line therapy 3:

• Naproxen sodium 500-825 mg at onset (maximum 1.5 g/day) 3
• Ibuprofen 400-800 mg 3
• Aspirin 900-1000 mg 3
• Combination: aspirin + acetaminophen + caffeine 1, 3

Administer as early as possible during the attack to improve efficacy. 1, 3

Add antiemetic 20-30 minutes before NSAID for synergistic analgesia 3:

• Metoclopramide 10 mg PO 3
• Prochlorperazine 25 mg PO 3

Moderate-to-Severe Migraine (First-Line):

Use triptans as first-line therapy 1, 3:

• Oral options: sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan 2.5 mg, zolmitriptan 2.5-5 mg 3
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with fastest onset (15 minutes) 3
• Intranasal sumatriptan 5-20 mg for patients with significant nausea/vomiting 3

Contraindications to triptans: ischemic heart disease, previous MI, uncontrolled hypertension, significant cardiovascular disease 3

Severe Migraine Requiring IV Treatment:

Recommended IV combination therapy 3:

• Metoclopramide 10 mg IV (provides direct analgesic effects plus treats nausea) 3
• PLUS Ketorolac 30 mg IV (rapid onset, 6-hour duration, minimal rebound risk) 3

Alternative IV options 3:

• Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, fewer side effects than chlorpromazine) 3
• Dihydroergotamine (DHE) IV for refractory cases 3

Avoid opioids (hydromorphone, meperidine) as they lead to dependency, rebound headaches, and loss of efficacy. 1, 3 Reserve only for cases where all other options are contraindicated and abuse risk has been addressed. 3

Critical Medication-Overuse Headache Prevention

Limit all acute medications to no more than 2 days per week to prevent medication-overuse headache (MOH). 1, 3 Frequent use (>2 times weekly) of NSAIDs, triptans, ergotamines, or analgesics causes paradoxical increase in headache frequency leading to daily headaches. 1, 3

If patient requires acute treatment >2 days/week, initiate preventive therapy 3:

• First-line preventive options: propranolol 80-240 mg/day, topiramate, amitriptyline 30-150 mg/day 3
• Preventive therapy reduces attack frequency and restores responsiveness to acute treatments 3

When Current Treatment Fails

If triptans stop working 3:

1. Try a different triptan (failure of one doesn't predict failure of others) 3
2. Ensure early administration (most effective when headache still mild) 3
3. Add fast-acting NSAID to prevent 48-hour recurrence 3
4. Change route (try subcutaneous if oral fails) 3
5. Escalate to newer agents: rimegepant, ubrogepant, zavegepant 3

Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates MOH. Instead, transition to preventive therapy. 3

Common Pitfalls to Avoid

• Never use EEG for routine headache evaluation (only for seizure-like symptoms) 1
• Don't restrict metoclopramide only to vomiting patients—nausea itself warrants treatment 3
• Avoid diphenhydramine routinely—not evidence-based for migraine 3
• Don't use prednisone in urgent care "headache cocktails"—limited evidence for acute treatment 3
• Ketorolac requires dose reduction in patients ≥65 years or with renal impairment 3