What is the approach to a headache workup and management?

Headache Workup and Management

Initial Assessment: Screen for Red Flags

The primary goal in headache evaluation is to distinguish benign primary headaches from life-threatening secondary causes through systematic red flag screening, followed by appropriate neuroimaging only when indicated. 1

Critical Red Flags Requiring Urgent Investigation

• Thunderclap headache (sudden, severe onset) 1
• New headache after age 50 1, 2
• Headache awakening patient from sleep 1, 3
• Progressive worsening or increased frequency 1, 3
• Abnormal neurologic examination (focal deficits, altered consciousness, papilledema) 1, 3
• Fever with headache 1
• Head trauma preceding headache 1
• "Worst headache of my life" 1
• Headache worsened by Valsalva maneuver 1
• History of dizziness, lack of coordination, numbness, or tingling 1

Neuroimaging Decision Algorithm

Obtain neuroimaging (MRI preferred over CT) only when red flags are present or neurologic examination is abnormal. 1

When to Image:

• Unexplained abnormal neurologic examination (Grade B recommendation) 1
• Any red flag present 1
• Atypical features not fulfilling migraine criteria (Grade C recommendation) 1

When NOT to Image:

• Normal neurologic examination with typical migraine features (Grade B recommendation) 1
• Routine primary headache without red flags 1, 3

Common pitfall: Neuroimaging can reveal clinically insignificant abnormalities (white matter lesions, arachnoid cysts, meningiomas) that alarm patients and trigger unnecessary testing. 1

Imaging Modality Selection:

• MRI is preferred for higher resolution and no radiation exposure 1
• Non-contrast CT followed by lumbar puncture if subarachnoid hemorrhage suspected 2
• CSF analysis to confirm/exclude hemorrhage, infection, tumor, or CSF pressure disorders 2

Diagnosis of Primary Headaches

Migraine Diagnostic Criteria (ICHD-3):

At least 2 of the following: 1

• Unilateral location
• Throbbing/pulsatile character
• Moderate to severe intensity
• Worsening with routine physical activity

Plus at least 1 of: 1

• Nausea/vomiting
• Photophobia and phonophobia

Tension-Type Headache:

At least 2 of: 1

• Bilateral location
• Pressing/tightening (non-pulsatile) quality
• Mild to moderate intensity
• No aggravation with routine activity
• Lacks migraine-associated symptoms 1

Cluster Headache:

• Strictly unilateral, severe headache lasting 15-180 minutes 1
• Ipsilateral cranial autonomic symptoms (conjunctival injection, lacrimation, nasal congestion) 1
• Frequency: 1-8 attacks per day 1

Acute Treatment Algorithm

First-Line (Over-the-Counter):

NSAIDs with strongest evidence: 1

• Aspirin (acetylsalicylic acid)
• Ibuprofen
• Diclofenac potassium
• Paracetamol (only if NSAID-intolerant)

Second-Line (Prescription):

Triptans for inadequate response to NSAIDs 1, 3

• Most effective when taken early while headache still mild 1, 3
• Do NOT use during aura phase 1
• If one triptan fails, try others 1
• Subcutaneous sumatriptan for rapid peak intensity or vomiting 1

Critical contraindications for triptans: 4

• Uncontrolled hypertension
• Coronary artery disease or risk factors
• Concurrent MAO-A inhibitor use
• History of coronary vasospasm

Emergency Department Treatment:

IV metoclopramide 10mg plus IV ketorolac 30mg as first-line therapy 3

• Avoid opioids entirely 3
• Provides rapid pain relief with synergistic analgesia 3

Medication-Overuse Headache Prevention:

Limit acute medication to ≤2 days per week 1

• Frequent use causes medication-overuse headache with increasing frequency leading to daily headaches 1
• Agents causing overuse: ergotamine, opiates, triptans, butalbital-containing compounds 1

Preventive Therapy Indications

Start preventive treatment when: 1

• ≥2 attacks per month producing disability ≥3 days/month 1
• Acute medication use >2 days per week 1
• Contraindication to or failure of acute treatments 1
• Headaches impair quality of life on ≥2 days/month despite optimized acute therapy 1

First-Line Preventive Options:

• Beta-blockers (propranolol) 1, 3
• Topiramate 3
• Candesartan 3

Chronic Migraine (≥15 headache days/month):

OnabotulinumtoxinA (Botox) for chronic migraine prevention 5

• Indicated for adults with ≥15 headache days/month lasting ≥4 hours each 5
• Not effective for episodic migraine (<15 days/month) 5

Patient Education and Expectations

Set realistic goal: control, not cure 1, 3

• Reduce attack frequency, duration, and disability 1
• Return control from disease to patient 1

Lifestyle Modifications:

• Maintain adequate hydration 3
• Regular meals 3
• Consistent sleep schedule 3
• Regular physical activity 3
• Stress management techniques 3

Common pitfall: Overemphasis on trigger avoidance can lead to unnecessary avoidance behavior damaging quality of life. 1 True triggers are often self-evident; menstruation is the most important exception. 1

Stepped Care Approach

Use stepped care to achieve optimal individualized therapy: 1

1. Start with first-line NSAIDs 1
2. Advance to triptans if inadequate response 1
3. Consider preventive therapy if using acute medications >2 days/week 1
4. Reassess and adjust based on response 1