What is the best course of action for persistent headache with cold symptoms lasting 3 months?

Persistent Headache with Cold Symptoms for 3 Months

A patient with headache and cold symptoms persisting for 3 months requires neuroimaging to exclude secondary causes, followed by evaluation for chronic migraine or post-viral persistent symptoms, with consideration of preventive therapy if migraine criteria are met.

Immediate Diagnostic Priorities

Red Flag Assessment

You must first exclude dangerous secondary causes before attributing symptoms to a primary headache disorder:

• Obtain neuroimaging now – The American Academy of Family Physicians recommends neuroimaging for nonacute headache that has worsened and persisted for 2 months, and your patient has exceeded this threshold at 3 months 1
• Assess for progressive worsening pattern, which suggests increased intracranial pressure or mass lesion 1
• Evaluate for neurological deficits indicating stroke, hemorrhage, or structural pathology 2, 1
• Determine if headache awakens from sleep or worsens with Valsalva maneuver, both concerning for secondary causes 1

Imaging Selection

• Non-contrast head CT is first-line for initial evaluation 2, 1
• Consider brain MRI with and without contrast if CT is unrevealing but symptoms persist, particularly given the 3-month duration 2

Diagnostic Considerations After Excluding Secondary Causes

Chronic Migraine Evaluation

If imaging is negative, determine whether this meets chronic migraine criteria:

• Chronic migraine requires ≥15 headache days per month for >3 months, with ≥8 days meeting migraine features (unilateral, pulsating, moderate-to-severe intensity, with nausea/vomiting, photophobia, or phonophobia) 3, 1
• Your patient's 3-month duration satisfies the temporal requirement 3
• Have the patient maintain a headache diary to document frequency and characteristics 1

Medication Overuse Headache

This is a critical pitfall to identify:

• Check if patient uses acute headache medications ≥10 days/month for triptans/ergots/combination analgesics, or ≥15 days/month for simple analgesics, sustained for ≥3 months 3, 1
• Medication overuse headache can perpetuate the cycle and must be addressed before preventive therapy will be effective 1

Post-Viral Persistent Symptoms

Given the "cold symptoms" component:

• Consider that persistent physical symptoms following viral infections can last several months, with multiple biological mechanisms including persistent inflammation, immune dysregulation, and symptom learning 4
• Post-viral symptoms commonly include fatigue, dyspnea, sleep disturbance, cough, myalgia, chest pain, and headache, with prevalence up to 12 months 5
• However, do not assume a benign post-viral course without excluding structural pathology first 1

Treatment Algorithm

If Chronic Migraine Criteria Are Met

First-line preventive therapy:

• Initiate CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) – The American College of Physicians designates these as first-line for chronic migraine prevention based on strong evidence reducing migraine days by 2-4.8 days per month 3
• Administered as monthly subcutaneous injections with minimal systemic side effects 3
• Monitor blood pressure with erenumab due to postmarketing warnings for hypertension development 3

Second-line if CGRP antibodies unavailable or ineffective:

• Topiramate 25 mg daily, titrating slowly to 100-200 mg daily over 2-3 months – this is the only traditional preventive with randomized controlled trial evidence specifically in chronic migraine 3
• Warn about cognitive slowing, paresthesias, weight loss, and kidney stone risk 3

Critical timing consideration:

• Start at low doses and allow 2-3 months to assess benefit – full preventive effect takes this long to manifest 3
• Continue appropriate acute therapy alongside preventive treatment 3

Acute Treatment Guidance

• For acute episodes: NSAIDs, acetaminophen, or triptans (sumatriptan 50-100 mg if no contraindications) 1
• Add antiemetics like metoclopramide or prochlorperazine for nausea and adjunctive pain relief 1
• Avoid opioids and butalbital 1
• Educate about medication overuse thresholds and limit acute medication use 3, 1

If Migraine Criteria Not Met

• Reassess after neuroimaging for alternative diagnoses including chronic sinusitis, tension-type headache, or persistent post-viral symptoms 4
• Most respiratory symptoms improve within 3 weeks, but 8% experience prolonged illness beyond this timeframe 6
• Consider referral to neurology or headache specialist for diagnostic clarification 1

Essential Patient Education

• Lifestyle modifications: adequate hydration, regular meals, sufficient sleep, physical activity, and stress management 1
• Maintain headache diary tracking frequency, severity, triggers, and medication use 1
• Re-consult if symptoms worsen or new neurological symptoms develop 1
• Understand that persistent physical symptoms can have multifactorial biological and psychosocial mechanisms requiring comprehensive management 4