Management of Acute Headache
Begin with immediate risk stratification to identify life-threatening secondary causes before treating as primary headache, then initiate early pharmacologic therapy based on headache severity and type. 1
Initial Risk Stratification: Red Flags Requiring Urgent Investigation
Rule out secondary causes first by screening for these specific red flags that mandate neuroimaging or further workup 1:
- Thunderclap onset (pain peaking within seconds to 1 minute) 2
- Rapidly increasing frequency of headaches 1
- Headache awakening patient from sleep 1
- Abrupt onset of severe headache in patient over 40 years 1, 2
- Focal neurologic signs or symptoms (weakness, vision changes, coordination problems) 1
- Persistent headache following head trauma 1
- Marked change in established headache pattern 1
- Presence of neck stiffness/meningismus 2
- Onset during exertion or sexual activity 1, 2
- Witnessed loss of consciousness 2
Neuroimaging Indications
Order CT head immediately if any red flags are present, or if the patient has atypical features with abnormal neurologic examination 1. Do not order neuroimaging for patients with normal neurologic examination and typical primary headache features who are not at higher risk than the general population 1.
Classification of Primary Headaches
Once secondary causes are excluded, classify the headache type using these specific diagnostic criteria 1:
Migraine Diagnostic Requirements (need ≥2 pain features + ≥1 associated feature):
Pain characteristics (at least 2 of) 1:
- Unilateral location
- Throbbing/pulsatile character
- Moderate to severe intensity
- Worsening with routine physical activity
Associated symptoms (at least 1 of) 1:
- Nausea and/or vomiting
- Photophobia AND phonophobia
Tension-Type Headache Diagnostic Requirements:
Pain characteristics (at least 2 of) 1:
- Pressing, tightening, or non-pulsatile character
- Mild to moderate intensity
- Bilateral location
- No aggravation with routine activity
Must have BOTH 1:
- No nausea or vomiting (anorexia acceptable)
- No photophobia AND phonophobia together (may have one or the other)
Cluster Headache Diagnostic Requirements:
Requires 5 attacks with severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes untreated, PLUS at least one ipsilateral autonomic feature 1:
- Lacrimation
- Nasal congestion or rhinorrhea
- Forehead/facial sweating
- Ptosis, miosis, or eyelid edema
Treatment Algorithm Based on Severity
Mild to Moderate Migraine (First-Line)
Start with NSAIDs immediately at headache onset 1, 3:
- Naproxen sodium 500-825 mg PO (can repeat every 2-6 hours, maximum 1.5 g/day) 3
- Ibuprofen 400-800 mg PO 3
- Aspirin 1000 mg PO 3
- Combination: Aspirin 250 mg + Acetaminophen 250 mg + Caffeine 65 mg (2 tablets) 1, 3
Add antiemetic 20-30 minutes before NSAID for synergistic analgesia 3:
Moderate to Severe Migraine (First-Line)
Combination therapy is superior to monotherapy 3:
- Sumatriptan 50-100 mg PO PLUS Naproxen sodium 500 mg PO (130 more patients per 1000 achieve sustained relief at 48 hours compared to either alone) 3
Alternative triptan options if sumatriptan fails or is contraindicated 1, 3, 4:
For patients with significant nausea/vomiting, use non-oral routes 3:
- Sumatriptan 6 mg subcutaneous (59% complete pain relief by 2 hours, most effective route) 3, 4
- Sumatriptan 5-20 mg intranasal spray 3
Severe Migraine Requiring IV Treatment
Optimal IV cocktail 3:
- Metoclopramide 10 mg IV (provides direct analgesic effect beyond antiemetic properties) 3
- Ketorolac 30 mg IV (60 mg IM if under age 65; reduce dose for age ≥65 or renal impairment) 3
Alternative IV options 3:
- Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, fewer side effects than chlorpromazine) 3
- Dihydroergotamine (DHE) IV or intranasal 3
Avoid opioids (hydromorphone, meperidine) except when all other options contraindicated, sedation acceptable, and abuse risk addressed 1, 3.
Critical Frequency Limitation to Prevent Medication-Overuse Headache
Restrict ALL acute medications to maximum 2 days per week 3, 4. Using acute treatments more than twice weekly leads to medication-overuse headache, creating a vicious cycle of daily headaches 3, 4. Initiate preventive therapy immediately if patient requires acute treatment more than twice weekly 3.
Contraindications Requiring Alternative Approach
Triptans are absolutely contraindicated in 4:
- Ischemic heart disease or previous myocardial infarction
- Prinzmetal's variant angina (coronary vasospasm)
- Uncontrolled hypertension
- History of stroke or TIA
- Wolff-Parkinson-White syndrome or other cardiac accessory pathway disorders
- Peripheral vascular disease
For patients with cardiovascular risk factors (age >40, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before first triptan dose 4. Consider administering first dose in medically supervised setting with ECG monitoring 4.
NSAIDs contraindicated in 3:
- Renal impairment (CrCl <30 mL/min)
- Active GI bleeding
- Aspirin/NSAID-induced asthma
When Initial Treatment Fails
If NSAIDs fail after 2-3 migraine episodes, escalate to triptan therapy 3. If one triptan fails, try a different triptan as failure of one does not predict failure of others 3. If all triptans fail after adequate trials, consider newer CGRP antagonists (rimegepant, ubrogepant, zavegepant) 3.
Ensure early administration as triptans work best when taken while headache is still mild 3, 4.
Transition to Preventive Therapy
Preventive therapy is indicated when 3:
- Headaches occur more than 2 days per week
- Two or more attacks per month producing disability lasting ≥3 days
- Contraindication to or failure of acute treatments
- Patient quality of life significantly impaired despite optimized acute therapy
First-line preventive options 3:
- Propranolol 80-240 mg/day
- Topiramate (dose titration required)
- Amitriptyline 30-150 mg/day (especially for mixed migraine/tension-type)