What is the initial approach to a patient presenting with a headache?

Initial Approach to Headache Presentation

The initial approach to a patient with headache must prioritize immediate identification of "red flag" features through focused history and examination to rule out life-threatening secondary causes before categorizing primary headache disorders. 1

Step 1: Screen for Red Flag Features Requiring Urgent Evaluation

Immediately assess for these critical warning signs that suggest secondary headache 2, 1:

• Sudden onset "thunderclap" headache - suggests subarachnoid hemorrhage 2
• Headache worsened by Valsalva maneuver, coughing, sneezing, or exercise - suggests intracranial hypertension or space-occupying lesion 2, 1
• Headache that awakens patient from sleep - suggests secondary pathology 1
• Progressive worsening pattern - suggests intracranial space-occupying lesion 2, 1
• New onset headache in patients >50 years of age - consider temporal arteritis or other secondary causes 2, 1
• Fever, neck stiffness, or signs of infection - suggests meningitis or subarachnoid hemorrhage 2, 1
• Focal neurological deficits on examination - suggests secondary headache 2, 1
• Headache with altered consciousness, personality changes, or memory impairment - suggests secondary headache 2, 1
• Associated weight loss - suggests secondary headache 2
• Atypical aura symptoms - consider TIA, stroke, or arteriovenous malformations 2
• History of head trauma - consider subdural hematoma 2

Step 2: Determine Need for Neuroimaging

Neuroimaging is warranted when red flags are present, but generally not needed for typical primary headache patterns with normal examination 1, 3:

Indications for urgent neuroimaging 1, 3:

• Unexplained abnormal findings on neurological examination
• New onset headache in patients over 50 years
• Atypical features that don't fit established primary headache patterns
• Focal neurological deficits
• Progressive worsening
• New neurological symptoms

Neuroimaging generally NOT warranted 1:

• Normal neurologic examination
• Features consistent with primary headache disorders
• Long history of similar headaches without change in pattern

MRI brain is the preferred imaging modality when indicated 3

Step 3: Characterize the Headache Pattern

Once secondary causes are excluded, obtain specific details to categorize primary headache type 1:

Key diagnostic questions 1:

• Location: unilateral vs bilateral
• Character: pulsating, pressing/tightening, stabbing
• Intensity: mild, moderate, severe
• Duration: 15-180 minutes (cluster), 4-72 hours (migraine), variable (tension-type)
• Frequency: episodic vs chronic (≥15 days/month for >3 months) 2, 1
• Associated symptoms:
  • Autonomic features (lacrimation, rhinorrhea, ptosis) suggest cluster headache 3
  • Photophobia, phonophobia, nausea/vomiting suggest migraine 2, 3
  • Aura symptoms suggest migraine with aura 2
• Behavioral response: restlessness/pacing (cluster) vs lying still in dark room (migraine) 3

Step 4: Implement Headache Diary

Ask patients to maintain a headache diary to track frequency, severity, triggers, and treatment response 1. This is critical because patients often cannot accurately report headache frequency without documentation 2. A practical screening question is: "Do you feel like you have a headache of some type on 15 or more days per month?" 2

Step 5: Assess for Medication Overuse

Evaluate current medication use to identify medication overuse headache, which occurs with frequent use of acute treatments 2, 1. Patients often report severe headache days but fail to mention milder headaches, leading to underestimation of medication use 2.

Common Pitfalls to Avoid

• Do not rely solely on patient recall of headache frequency - always recommend a headache diary 2, 1
• Do not order neuroimaging reflexively - it is not warranted for typical primary headaches with normal examination 1, 4
• Do not prescribe opioids - they are ineffective for headache management and carry dependency risk 2, 1, 4, 5
• Do not overlook temporal arteritis in patients >50 years - this requires urgent evaluation 2
• Do not miss progressive headache patterns - these suggest space-occupying lesions 2, 1

When to Refer to Neurology

Consider referral for 1, 6:

• Cluster headaches
• Uncertain diagnosis
• Poor response to preventive strategies
• Migraine with persistent aura
• Headache with motor weakness
• Unremitting headache despite appropriate management