What is the initial assessment and treatment approach for a patient presenting with a headache?

Initial Assessment and Treatment of Headache

Begin by immediately screening for red flags that indicate life-threatening secondary causes requiring urgent intervention, then systematically apply ICHD-3 diagnostic criteria to identify the specific headache type, and initiate appropriate acute treatment based on headache severity and characteristics. 1

Immediate Red Flag Assessment

The first priority is identifying dangerous secondary headaches through specific red flags 1:

• Focal neurologic deficits (weakness, sensory loss, visual field defects) 1
• Altered consciousness or confusion 1
• Headache awakening patient from sleep 1, 2
• Progressive worsening pattern 1
• Sudden onset "thunderclap" headache (peak intensity within seconds to minutes) 3, 4
• New headache in patients over age 50 2
• Fever with headache (suggests meningitis) 4

If any red flags are present, immediately obtain non-contrast CT scan and consider lumbar puncture if subarachnoid hemorrhage is suspected but CT is negative. 3

Detailed History Taking

For patients without red flags, obtain these specific details to diagnose primary headache 3:

Temporal Characteristics

• Age at onset (onset at/around puberty suggests migraine) 3
• Duration of individual episodes (4-72 hours suggests migraine) 3
• Frequency (≥15 days/month for >3 months suggests chronic migraine) 3
• Pattern of onset (gradual vs sudden) 3

Pain Characteristics

• Location (unilateral suggests migraine) 3
• Quality (pulsating/throbbing suggests migraine) 3
• Intensity (moderate to severe suggests migraine) 3
• Aggravation by routine physical activity (suggests migraine) 3

Associated Symptoms

• Nausea and/or vomiting 3
• Photophobia and phonophobia 3
• Aura symptoms (visual, sensory, speech/language disturbances lasting 5-60 minutes) 3

Additional Critical Information

• Family history of migraine (strengthens diagnosis) 3
• Current acute and preventive medication use (≥10 days/month of acute medication for >3 months suggests medication-overuse headache) 3
• Over-the-counter medication frequency (often underreported) 2

Physical Examination

Perform focused neurologic examination including fundoscopic exam and assessment for nuchal rigidity. 4, 5

In patients over 50 with new headache, check ESR and CRP to exclude temporal arteritis. 2

Neuroimaging is NOT indicated for typical primary headache without red flags or abnormal neurologic examination. 1

Acute Treatment Algorithm

For Severe Headache in Emergency Setting

Administer IV metoclopramide 10mg plus IV ketorolac 30mg as first-line therapy—this combination provides the most effective rapid pain relief with synergistic analgesia. 1

Avoid opioids entirely as they are ineffective for acute migraine and increase risk of medication-overuse headache. 1, 6

For Moderate Migraine in Outpatient Setting

Triptans are most effective when taken early while headache is still mild. 1, 7

• Sumatriptan 50-100mg orally achieves headache response (reduction to mild or no pain) in 61-62% at 2 hours and 78-79% at 4 hours 7
• The 50mg and 100mg doses show no statistical difference in efficacy 7
• Allow second dose 4-24 hours after initial treatment if headache recurs 7

Alternative first-line options include NSAIDs (ibuprofen, naproxen) or combination therapy with NSAID plus triptan. 3

Common Pitfalls to Avoid

Do not start daily analgesics for chronic daily headache—this leads to medication-overuse headache and worsens the problem. 2

Do not obtain neuroimaging for typical migraine presentations without red flags—this wastes resources and exposes patients to unnecessary radiation. 1

Do not prescribe combined hormonal contraceptives to women with migraine with aura—this increases stroke risk. 3

When to Consider Specific Secondary Causes

Obstructive Sleep Apnea

Morning headaches that resolve within hours of waking are classic for OSA—refer for sleep study if patient has snoring, obesity, or daytime fatigue. 2

Medication-Overuse Headache

Suspect when patient uses acute headache medication ≥10 days/month for >3 months (or non-opioid analgesics ≥15 days/month). 3, 2

Subarachnoid Hemorrhage

For suspected SAH with negative third-generation CT performed within 6 hours and read by neuroradiologist, lumbar puncture is not required. 3

If CT is lower generation, performed after 6 hours, or not read by experienced radiologist, perform lumbar puncture with xanthochromia evaluation (ideally after 12 hours from onset). 3

Follow-Up and Preventive Therapy

Evaluate treatment response 2-3 months after initiation, then every 6-12 months. 3

Consider preventive therapy when headaches impair quality of life on ≥2 days/month despite optimized acute therapy, or when patient uses acute medications >2 days/week. 3

First-line preventive options include beta-blockers, topiramate, and candesartan. 3

Specialist Referral Indications

Refer to specialist when diagnosis is uncertain, treatment fails despite multiple medication trials, or significant comorbidities complicate management—approximately 90% of migraine patients should be managed in primary care. 3