What is the appropriate management for a patient presenting with a headache?

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:

• Metoclopramide 10 mg PO 3
• Prochlorperazine 25 mg PO 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 1, 3:

• Rizatriptan 10 mg PO 1, 3
• Naratriptan 2.5 mg PO 1
• Zolmitriptan 2.5-5 mg PO 1

Severe Migraine with Nausea/Vomiting (Parenteral Route)

First-line IV combination 3:

• Metoclopramide 10 mg IV (provides direct analgesic effect through dopamine antagonism, not just antiemetic) 3
• PLUS Ketorolac 30 mg IV (60 mg IM if under 65 years; reduce dose for age ≥65 or renal impairment) 1, 3

Alternative IV options 3:

• Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide with 21% adverse event rate vs 50% for chlorpromazine) 3
• Dihydroergotamine (DHE) 0.5-1 mg IV or intranasal 1, 3

Subcutaneous option for fastest relief 3:

• Sumatriptan 6 mg SC (59% complete pain relief by 2 hours, peak concentration at 15 minutes—fastest of all routes) 3, 4
• Maximum 2 doses in 24 hours 3

Contraindications to Triptans (Use Alternative Agents)

Triptans are absolutely contraindicated in 4:

• Ischemic heart disease or previous myocardial infarction
• Prinzmetal's angina (coronary vasospasm)
• Uncontrolled hypertension
• History of stroke or TIA
• Peripheral vascular disease
• Wolff-Parkinson-White syndrome or other cardiac accessory pathway disorders

For patients with cardiovascular risk factors, perform cardiovascular evaluation before first triptan dose; if multiple risk factors present, administer first dose in medically supervised setting with ECG monitoring 4.

Alternative agents when triptans contraindicated 3:

• Rimegepant, ubrogepant, or zavegepant (CGRP antagonists) 3
• Dihydroergotamine (DHE) 3

Critical Medication Frequency Limitation

Limit ALL acute headache medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 3, 4. This applies to NSAIDs, triptans, ergotamines, opioids, and combination analgesics 1, 4.

If patient requires acute treatment more than twice weekly, initiate preventive therapy immediately 3:

• First-line preventive options: Propranolol 80-240 mg/day, topiramate, divalproex sodium, or amitriptyline 30-150 mg/day 3

Medications to Avoid

Opioids should be avoided as they lead to dependency, rebound headaches, and loss of efficacy 1, 3. Reserve only for cases where all other medications are contraindicated, sedation is acceptable, and abuse risk has been addressed 3.

Butorphanol nasal spray has better evidence than other opioids if one must be used 3.

Treatment Failure Algorithm

If initial treatment fails after 2-3 migraine episodes 3:

1. Try a different triptan (failure of one does not predict failure of others) 3
2. Change route of administration (e.g., subcutaneous or intranasal if oral failed) 3
3. Add fast-acting NSAID to prevent 48-hour recurrence (occurs in 40% of patients) 3
4. Ensure early administration (triptans most effective when taken during mild pain phase) 3, 4
5. Escalate to third-line agents (ditans or gepants) if all triptans fail 3
6. Initiate preventive therapy if headaches impair quality of life despite optimized acute treatment 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for headache to worsen—early administration improves efficacy 1, 4
• Do not allow patients to increase acute medication frequency in response to treatment failure—this creates medication-overuse headache cycle 3
• Do not assume chest/throat/jaw tightness after triptan is cardiac—usually non-cardiac, but perform cardiac evaluation in high-risk patients 4
• Do not use acetaminophen alone for migraine—ineffective as monotherapy but works in combination with aspirin and caffeine 1
• Do not restrict metoclopramide only to vomiting patients—nausea itself warrants treatment and metoclopramide provides independent analgesic benefit 3