What is the initial management for a patient presenting with a generalized headache?

Initial Management of Generalized Headache

The initial management of generalized headache must begin with immediate assessment for red flag features that indicate secondary causes requiring urgent intervention, followed by classification into primary versus secondary headache types to guide treatment. 1, 2

Immediate Red Flag Assessment

Your first priority is identifying dangerous secondary causes. Evaluate for these critical warning signs:

• Abrupt onset of severe headache ("thunderclap" pattern) 3
• Headache awakening patient from sleep 1, 2
• Headache worsened by Valsalva maneuver 2
• Progressive worsening pattern 2
• New onset in patients over 50 years 1, 2
• Fever or signs of infection 2
• Focal neurologic signs or symptoms 3, 1
• Marked change in headache pattern 3
• Persistent headache following head trauma 3
• History of uncoordination 3
• Rapidly increasing frequency 3

If any red flags are present, obtain neuroimaging immediately. Non-contrast head CT is first-line in acute settings for suspected hemorrhage, though brain MRI with and without contrast is preferred when available for superior detection of masses, ischemia, and structural abnormalities. 1 A lower threshold for neuroimaging is recommended in patients over 50, even without classic red flags. 1

If CT/MRI is normal but subarachnoid hemorrhage is suspected, perform lumbar puncture for CSF analysis. 1

Focused History for Primary Headache Classification

If no red flags are present and neurologic examination is normal, neuroimaging is generally not warranted. 2 Instead, obtain specific details to classify the primary headache type:

Key Diagnostic Questions

• Frequency and timing: How many headache days per month? What time of day? 3
• Location: Unilateral versus bilateral? Front, back, or over/behind one eye? 3
• Character: Throbbing versus pressing/tightening? 3, 1
• Intensity: Mild-to-moderate versus moderate-to-severe? 1
• Duration: Hours versus days? 3, 2
• Associated symptoms: Nausea/vomiting? Photophobia/phonophobia? Visual aura? Neck pain? 3, 1
• Aggravating factors: Worsening with routine physical activity? 1
• Current medication use: Over-the-counter analgesics? Prescription medications? Frequency of use? 3

Distinguishing Primary Headache Types

Migraine features: Unilateral location, throbbing character, moderate-to-severe intensity, worsening with routine activity, associated nausea/vomiting or photophobia/phonophobia. 1

Tension-type headache features: Bilateral location, pressing/tightening (non-pulsatile) character, mild-to-moderate intensity, no aggravation by routine activity. 1

Cervicogenic headache features: Associated neck pain and restricted cervical range of motion. 1 Note that medical imaging is not diagnostic for cervicogenic headache etiology. 1

Critical Medication Overuse Assessment

Before initiating any treatment, assess for medication overuse headache, which can perpetuate chronic headache patterns:

• Triptans, ergots, or combination analgesics: ≥10 days per month for ≥3 months 1, 2
• Simple analgesics: ≥15 days per month for ≥3 months 1, 2

If medication overuse is present, this must be addressed as part of the treatment plan. 2, 4

Acute Treatment Based on Headache Type

For Migraine

First-line acute treatment options:

• Sumatriptan tablets 50-100 mg: Provides headache response in 50-62% at 2 hours and 68-79% at 4 hours compared to 17-38% with placebo. 1 However, avoid in patients with cardiovascular disease due to vasoconstrictive properties. 5
• NSAIDs or acetaminophen with caffeine combinations for mild-to-moderate attacks 5
• Gepants (rimegepant or ubrogepant): Eliminate headache in 20% of patients at 2 hours, safe in cardiovascular disease, with adverse effects of nausea and dry mouth in 1-4%. 5

For Tension-Type Headache

• NSAIDs or acetaminophen are appropriate first-line treatments 5

For Cervicogenic Headache

• Exercise treatment is beneficial across neck pain presentations 1

Preventive Therapy Considerations

Consider preventive medications if:

• ≥15 headache days per month for >3 months (chronic migraine definition) 1, 2
• Episodic migraine occurs frequently or acute treatment provides inadequate response, with no absolute minimum number of headache days required 6
• Significant functional disability despite adequate acute treatment 6

First-Line Preventive Options for Chronic Migraine

CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) are first-line preventive therapy, reducing migraine days by 2-4.8 days per month with monthly subcutaneous injections and minimal systemic side effects. 1, 6 Monitor blood pressure with erenumab due to postmarketing warnings for hypertension development or worsening. 6

Second-Line Preventive Options

Topiramate 25-100 mg daily is a second-line option. Start at 25 mg daily and titrate slowly over 2-3 months to assess benefit. 1, 6 Common side effects include cognitive slowing, paresthesias, weight loss, and kidney stones. 6

Referral Indications

Refer to neurology for:

• Cluster headaches 2, 4
• Uncertain diagnosis 1, 2, 4
• Poor response to initial management or preventive strategies 1, 2, 4
• Migraine with persistent aura 2, 4
• Headache with motor weakness 2, 4
• Chronic migraine after initial evaluation 1

Common Pitfalls to Avoid

• Do not assume primary headache disorder without thorough evaluation for secondary causes, especially in patients over 50. 1
• Do not wait for an arbitrary number of headache days before considering prevention—focus on functional impairment and treatment response. 6
• Avoid opioids for regular headache management due to risk of dependency and rebound headaches. 2
• Avoid valproate in women of childbearing potential due to teratogenic effects. 1
• Do not abandon preventive therapy prematurely—full benefit may take 2-3 months to manifest. 6

Patient Education and Follow-Up

• Maintain a headache diary to track frequency, severity, triggers, and treatment response. 2
• Identify and avoid personal triggers, establish regular sleep patterns, and consider stress management techniques. 2
• Understand proper medication use to avoid rebound headaches. 2