Initial Management of Headache with Normal Blood Pressure and No Fever
This patient requires immediate risk stratification to exclude dangerous secondary causes before assuming a primary headache disorder, with the key first step being a focused neurologic examination and assessment for red flag features that would mandate urgent neuroimaging. 1, 2
Immediate Assessment Priority
The absence of fever (afebrile) is reassuring against infectious etiologies like meningitis or encephalitis, and the blood pressure of 125/76 mmHg is normal, ruling out hypertensive emergency as a cause. 3 However, do not assume this is a benign primary headache without first screening for red flags. 1, 4
Critical Red Flags to Assess Immediately
Perform a focused evaluation for the following features that indicate secondary headache requiring urgent intervention: 1, 2
- Thunderclap onset (sudden, severe, maximal at onset) - suggests subarachnoid hemorrhage 1
- Headache worsened by Valsalva maneuver, coughing, or sneezing - suggests increased intracranial pressure 3, 2
- Headache that awakens patient from sleep - suggests space-occupying lesion 3, 2
- Progressive worsening pattern - suggests tumor or subdural hematoma 3, 1
- Any focal neurologic deficits on examination - mandates immediate imaging 1, 2
- Altered mental status or confusion - consider encephalitis or other CNS pathology 3
- New onset in patient >50 years old - requires aggressive workup for temporal arteritis, tumor, or stroke 1
Management Algorithm Based on Red Flag Assessment
If Red Flags Present:
Obtain urgent neuroimaging before any treatment. 1 MRI of the brain is preferred for detecting tumors, stroke, and structural lesions, while non-contrast CT should be used only for thunderclap headache or recent trauma. 1 Any abnormal neurologic examination finding mandates immediate imaging. 3, 1
If No Red Flags and Normal Neurologic Exam:
Proceed with acute symptomatic treatment for presumed primary headache: 3, 2
First-line treatment: NSAIDs taken early in the headache phase 3, 2
- Ibuprofen 400-800 mg every 6 hours 2
- Naproxen sodium 275-550 mg every 2-6 hours 2
- Acetylsalicylic acid (aspirin) 3
- Diclofenac potassium 3
Second-line treatment: If NSAIDs fail after adequate trial, use triptans for moderate-to-severe headache 3, 2. Triptans are most effective when taken early when headache is still mild. 3
Adjunct therapy: For associated nausea/vomiting, add prokinetic antiemetics like metoclopramide or domperidone. 3 Metoclopramide given intravenously may also serve as monotherapy for acute attacks. 3
Critical Pitfalls to Avoid
- Do not start daily analgesics without establishing diagnosis, as frequent use (>2 times per week) risks medication-overuse headache. 3, 2
- Avoid opioids and barbiturates - questionable efficacy, risk of dependency, and rebound headaches. 3, 2
- Avoid oral ergot alkaloids - poorly effective and potentially toxic. 3
- Do not skip temporal arteritis workup if patient is >50 years old - check ESR and CRP to prevent permanent vision loss. 1
Follow-up Considerations
If headaches occur more than twice weekly despite acute treatment, consider preventive therapy with topiramate, gabapentin, amitriptyline, or valproate. 2 Refer to neurology for atypical features, difficult-to-manage cases, or chronic daily headache requiring prophylactic therapy. 1