What is the approach to managing headaches in patients?

Headache Approach and Management

Immediate Red Flag Screening

Begin by screening for life-threatening secondary causes that require urgent neuroimaging or emergency referral before proceeding with any other evaluation. 1

Critical red flags requiring immediate action include:

• Sudden-onset severe headache ("thunderclap") reaching maximal intensity immediately—obtain non-contrast head CT within 6 hours, followed by lumbar puncture if CT is negative to rule out subarachnoid hemorrhage 1
• New neurological deficits—mandate immediate MRI (preferred over CT) 1
• Age >50 years with new-onset headache—increases risk of temporal arteritis, subdural hematoma, or neoplasm to 15%; obtain ESR/CRP and neuroimaging 1
• Fever or signs of infection—consider meningitis/encephalitis requiring urgent lumbar puncture 1
• Headache worsened by Valsalva, cough, or positional changes—suggests increased intracranial pressure from mass lesion or Chiari malformation 1
• Headache awakening patient from sleep 1
• Progressive worsening pattern 1
• Abnormal neurological examination 1

If any red flags are present, do not proceed with primary headache management—refer emergently. 1

Diagnostic History for Primary Headaches

Once secondary causes are excluded, obtain specific details to differentiate primary headache types:

Frequency and Duration

• Chronic migraine: ≥15 headache days per month for >3 months with ≥8 days having migraine features 1
• Episodic migraine: 4-72 hours per attack 2, 1
• Cluster headache: 15-180 minutes per attack 1
• Tension-type headache: variable duration 1

Location and Quality

• Unilateral throbbing: suggests migraine (though ~40% report bilateral pain) 2, 1
• Bilateral pressing/tightening: suggests tension-type headache 1
• Strictly unilateral with autonomic symptoms (tearing, nasal congestion, ptosis): suggests cluster headache 1

Associated Symptoms

• Photophobia, phonophobia, nausea, vomiting: characteristic of migraine 2
• Prodromal symptoms (depressed mood, yawning, fatigue, cravings): suggest migraine 2
• Aura (transient neurological disturbances): occurs in approximately one-third of migraine patients 2

Medication History

• Document all over-the-counter and prescription medications used 2
• Screen for medication overuse: using acute medications >10 days per month causes medication-overuse headache 1

Trigger Identification

• Stress, weather changes, odors (perfume, chemicals, smoke) 2
• Dietary factors: recent meals, missed meals, specific foods/beverages in past 24 hours 2
• Sleep patterns and whether headaches awaken from sleep 2
• Sexual activity 2
• Hormonal changes 3

Physical and Neurological Examination

Perform a complete neurological examination to identify any focal signs that would contraindicate primary headache diagnosis. 3

Essential examination components:

• Vital signs: blood pressure (screen for hypertension), temperature (rule out infection) 3
• Cranial nerve function 3
• Mental status changes 3
• Focal neurological signs 3
• Neck stiffness (meningeal signs) 4

Neuroimaging Decisions

In patients with normal neurologic examination and no red flags, neuroimaging is usually not warranted. 2

Neuroimaging indications:

• Nonacute headache with unexplained findings on neurologic examination 2
• Any red flag features present 1
• Atypical features or headache not meeting strict migraine definition—use lower threshold 2
• MRI preferred over CT when neuroimaging is indicated due to higher resolution and lack of ionizing radiation 3

Acute Treatment Based on Headache Type

Episodic Migraine (Mild-to-Moderate)

For mild-to-moderate migraine attacks, use NSAIDs or acetaminophen combined with caffeine as first-line therapy. 1, 5

• Acetaminophen with aspirin and caffeine: effective combination (acetaminophen alone not beneficial) 2
• NSAIDs: ibuprofen, naproxen, ketorolac 2, 5
• Administer as early as possible during attack to improve efficacy 2

Episodic Migraine (Moderate-to-Severe)

For moderate-to-severe migraine attacks, triptans are first-line therapy but require cardiovascular screening. 1, 5

Triptan considerations:

• Eliminate pain in 20-30% of patients by 2 hours 5
• Contraindications: coronary artery disease, uncontrolled hypertension, stroke history, Wolff-Parkinson-White syndrome, Prinzmetal's angina 1, 6
• Adverse effects: transient flushing, tightness, or tingling in upper body in 25% of patients 5
• Do not use within 24 hours of ergot-type medications 6

Alternative acute therapies:

• Gepants (rimegepant, ubrogepant): CGRP receptor antagonists eliminate headache in 20% at 2 hours; adverse effects include nausea and dry mouth in 1-4% 5
• Lasmiditan: 5-HT1F agonist, safe in patients with cardiovascular risk factors 5

Cluster Headache

For cluster headache acute treatment, use subcutaneous sumatriptan 6 mg or 100% oxygen at 12 L/min via non-rebreather mask. 1

Preventive Therapy Indications

Initiate preventive therapy if patient has >2 headaches per week or meets criteria for chronic migraine. 2, 1

Chronic Migraine Prevention (Mandatory)

For chronic migraine (≥15 headache days/month), prophylactic therapy is mandatory. 1

First-line options:

• Topiramate 1
• OnabotulinumtoxinA 1
• Propranolol or timolol 1
• Amitriptyline 1
• Valproate 1
• Gabapentin 1

Expected benefit: Reduce migraine by 1-3 days per month relative to placebo 5

Cluster Headache Prevention

Verapamil 360 mg/day is first-line prophylaxis for cluster headache, with ECG monitoring for PR interval prolongation. 1

Medication-Overuse Headache Management

If patient uses acute medications >10 days per month, diagnose medication-overuse headache and initiate immediate preventive therapy while detoxifying from overused medications. 1

Critical management steps:

• Withdraw overused medications (expect transient worsening of headache during withdrawal) 1, 6
• Start preventive therapy immediately 1
• Avoid opioids or butalbital-containing compounds except as rare rescue medication—these are most likely to cause medication-overuse headache 1

Patient Education and Self-Management

Instruct patients to maintain a headache diary to track frequency, duration, intensity, and associated factors. 1, 3, 6

Essential education components:

• Identify and avoid personal triggers 1
• Establish regular sleep patterns to reduce migraine frequency 1
• Understand medication overuse risk: using acute drugs ≥10 days/month leads to headache exacerbation 6
• Recognize cardiovascular warning signs: chest pain, shortness of breath, irregular heartbeat, significant blood pressure rise, weakness, slurring of speech 6
• Avoid triptans within 24 hours of other triptans or ergot medications 6
• Be aware of serotonin syndrome risk when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 6

Common Pitfalls to Avoid

• Do not routinely order neuroimaging in patients with normal examination and no red flags—this is cost-ineffective and unnecessary 2, 3
• Do not prescribe triptans without cardiovascular screening—they cause vasospasm and are contraindicated in coronary artery disease 6, 5
• Do not allow frequent acute medication use (>10 days/month) without preventive therapy—this causes medication-overuse headache 1, 6
• Do not miss temporal arteritis in patients >50 years with new-onset headache—obtain ESR/CRP 1
• Do not assume bilateral headache excludes migraine—40% of migraine patients report bilateral pain 2