Headache Evaluation and Management: PowerPoint Presentation with MCQs
Slide 1: Red Flag Screening - When to Act Immediately
Screen every headache patient for life-threatening secondary causes before proceeding with any other evaluation. 1
Immediate red flags requiring urgent neuroimaging or emergency referral include: 1
- Sudden-onset severe headache ("thunderclap")
- New neurological deficits on examination
- Age >50 years with new-onset headache
- Fever or signs of infection
- Headache worsened by Valsalva, cough, or positional changes
- Headache awakening patient from sleep
- Progressive worsening pattern
- Abnormal neurological examination
MCQ 1: A 55-year-old woman presents with her first severe headache that started suddenly 2 hours ago while lifting groceries. What is the most appropriate next step?
- A) Prescribe sumatriptan and schedule follow-up
- B) Order urgent neuroimaging
- C) Start preventive therapy with propranolol
- D) Reassure and recommend ibuprofen
Answer: B - Age >50 with new-onset headache plus sudden onset requires urgent neuroimaging to exclude subarachnoid hemorrhage or other secondary causes. 1
Slide 2: Essential History Components
Medical history is the mainstay of headache diagnosis. 2
Document the following critical elements: 2
- Age at onset of headache
- Duration of individual headache episodes
- Frequency of headache episodes (days per month)
- Pain characteristics: location (unilateral vs bilateral), quality (pulsating vs pressing), severity, aggravating factors
- Accompanying symptoms: photophobia, phonophobia, nausea, vomiting
- Aura symptoms if present (visual, sensory, speech disturbances)
- All medications used - both over-the-counter and prescription 1
Screen specifically for medication overuse: using acute medications >10 days per month defines medication overuse. 1
MCQ 2: Which feature is most specific for migraine rather than tension-type headache?
- A) Bilateral location
- B) Pressing quality
- C) Photophobia AND phonophobia together
- D) Mild intensity
Answer: C - Tension-type headaches typically don't have both photophobia and phonophobia together, while migraines commonly have both. 3
Slide 3: Recognizing Migraine Without Aura
Suspect migraine without aura in patients with recurrent moderate to severe headache, particularly if pain is unilateral and/or pulsating, with accompanying symptoms. 2
Key diagnostic features: 2
- Recurrent headache attacks lasting 4-72 hours
- Unilateral location (though ~40% report bilateral pain)
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by routine physical activity
- Associated symptoms: photophobia, phonophobia, nausea, vomiting
Prodromal symptoms can precede pain onset: depressed mood, yawning, fatigue, cravings. 2
MCQ 3: A 28-year-old woman has monthly headaches lasting 8-12 hours with throbbing right-sided pain, nausea, and sensitivity to light. She has no aura. What is the diagnosis?
- A) Tension-type headache
- B) Migraine without aura
- C) Cluster headache
- D) Medication overuse headache
Answer: B - Unilateral, throbbing, moderate-severe pain with nausea and photophobia lasting 4-72 hours defines migraine without aura. 2
Slide 4: Migraine With Aura - Recognition and Differentiation
Suspect migraine with aura in patients with the above symptoms plus recurrent, short-lasting visual and/or hemisensory disturbances. 2
Aura characteristics: 2
- Occurs in ~one-third of migraine patients
90% experience visual aura (classically fortification spectra)
- ~31% have sensory symptoms (unilateral paresthesia spreading gradually in face or arm)
- Symptoms spread gradually over ≥5 minutes and occur in succession
- Less common: aphasic speech disturbance, brainstem symptoms, motor weakness, retinal symptoms
Critical differentiation from TIA: Aura symptoms spread gradually (≥5 minutes) and occur in succession, whereas TIA symptoms have sudden, simultaneous onset. 2
MCQ 4: What feature best distinguishes migraine aura from transient ischemic attack?
- A) Presence of visual symptoms
- B) Gradual spread of symptoms over ≥5 minutes
- C) Unilateral location
- D) Duration less than 1 hour
Answer: B - The gradual spreading quality of aura symptoms distinguishes them from the sudden, simultaneous onset of TIA symptoms. 2
Slide 5: Chronic Migraine and Medication Overuse Headache
Suspect chronic migraine in patients with ≥15 headache days per month. 2
Chronic migraine diagnostic criteria: 2
- ≥15 headache days per month for >3 months
- ≥8 days per month with migraine features
Medication overuse headache (MOH) criteria: 2
- Headache on ≥15 days/month in a patient with pre-existing headache disorder
- Regular overuse for >3 months: non-opioid analgesics on ≥15 days/month OR any other acute medication on ≥10 days/month
- Not better accounted for by another diagnosis
Educate all patients about MOH risk with frequent acute medication use. 2
MCQ 5: A patient with known migraine now has headaches 20 days per month and uses ibuprofen 18 days per month for 4 months. What is the most likely diagnosis?
- A) Chronic migraine alone
- B) Medication overuse headache
- C) New secondary headache
- D) Tension-type headache
Answer: B - Using non-opioid analgesics ≥15 days/month for >3 months in a patient with pre-existing headache defines medication overuse headache. 2
Slide 6: Tension-Type Headache Recognition
Tension-type headaches are bilateral with pressing, tightening, or non-pulsatile character, mild to moderate severity. 3
Distinguishing features from migraine: 3
- Bilateral location (not unilateral)
- Pressing/tightening quality (not pulsating)
- Mild to moderate intensity (not severe)
- NOT aggravated by routine physical activity
- Lacks nausea/vomiting (though may have anorexia)
- Does NOT have both photophobia AND phonophobia together
Routine neuroimaging is not indicated for typical tension-type headaches without red flags. 3
MCQ 6: Which feature would argue AGAINST tension-type headache?
- A) Bilateral location
- B) Worsening with climbing stairs
- C) Pressing quality
- D) Mild intensity
Answer: B - Aggravation by routine physical activity is characteristic of migraine, not tension-type headache. 3
Slide 7: Physical Examination and Neuroimaging Decisions
Perform a complete neurological examination to identify focal signs that contraindicate primary headache diagnosis. 1
Essential examination components: 1
- Vital signs
- Complete cranial nerve function
- Mental status assessment
- Focal neurological signs
Neuroimaging indications: 1
- Neuroimaging is usually NOT warranted with normal neurologic examination and no red flags
- Indicated for: unexplained abnormal neurologic examination findings, red flag features, or atypical features
The yield of neuroimaging in patients with normal examination is quite low - studies show brain tumors in 0.8%, AVMs in 0.2%, aneurysms in 0.1%. 4
MCQ 7: A 32-year-old with typical migraine features and completely normal neurological examination asks about getting an MRI. What should you recommend?
- A) MRI is mandatory for all migraines
- B) Neuroimaging is not warranted
- C) CT scan only
- D) MRI only if headaches persist 6 months
Answer: B - Neuroimaging is usually not warranted in patients with normal neurologic examination and no red flags. 1
Slide 8: Acute Treatment Algorithm
Use NSAIDs or acetaminophen combined with caffeine as first-line therapy for mild-to-moderate migraine attacks. 1
First-line acute treatment: 2
- NSAIDs: acetylsalicylic acid, ibuprofen, or diclofenac potassium
- Acetaminophen with caffeine
Second-line treatment - Triptans for moderate-to-severe attacks: 1
- Triptans are first-line for moderate-to-severe migraine
- Eliminate pain in 20-30% of patients by 2 hours 5, 6
- Require cardiovascular screening - avoid in patients with or at high risk for cardiovascular disease due to vasoconstrictive properties 6
- Adverse effects: transient flushing, tightness, or tingling in upper body in 25% 6
When triptans provide insufficient relief, combine with fast-acting NSAIDs. 2
Third-line options: 6
- Gepants (rimegepant, ubrogepant): eliminate headache in 20% at 2 hours, adverse effects include nausea and dry mouth in 1-4%
- Lasmiditan (5-HT1F agonist): safe in patients with cardiovascular risk factors
Critical principle: Early initiation and adequate first dosing. 7
MCQ 8: A 45-year-old with history of coronary artery disease has moderate-to-severe migraine. Which acute treatment should be avoided?
- A) Ibuprofen
- B) Sumatriptan
- C) Acetaminophen
- D) Lasmiditan
Answer: B - Triptans should be avoided in patients with cardiovascular disease due to vasoconstrictive properties; lasmiditan is safer in this population. 6
Slide 9: Preventive Therapy - When and What
Initiate preventive therapy if patient has >2 headaches per week or meets criteria for chronic migraine. 1
First-line preventive options: 1
- Topiramate (preferred for patients with obesity due to weight loss effect) 2
- OnabotulinumtoxinA
- Propranolol or timolol
- Amitriptyline (preferred for patients with depression or sleep disturbances) 2
- Valproate (absolutely contraindicated in women of childbearing potential) 2
- Gabapentin
For chronic migraine specifically: topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies are evidence-based options. 2
Preventive medications reduce migraine by 1-3 days per month relative to placebo. 6
Successful treatment requires: low-dose initiation with careful titration and monitoring of headache frequency. 7
MCQ 9: A 26-year-old woman with 8 migraine days per month who is planning pregnancy asks about prevention. Which medication is absolutely contraindicated?
- A) Propranolol
- B) Valproate
- C) Topiramate
- D) Amitriptyline
Answer: B - Valproate is absolutely contraindicated in women of childbearing potential. 2
Slide 10: Managing Medication Overuse Headache
Manage established MOH by explanation and withdrawal of the overused medication; abrupt withdrawal is preferred except for opioids. 2
Management approach: 2
- Educate patients about MOH risk
- Withdraw overused medication (abrupt withdrawal preferred)
- Once MOH is ruled out, initiate preventive medication therapy for chronic migraine
Opioids should always be avoided in headache treatment. 7
Recognize risk factors for transformation from episodic to chronic migraine: obesity is an important modifiable risk factor. 2
Refer patients with chronic migraine to specialist care. 2
MCQ 10: A patient with chronic migraine and confirmed medication overuse headache using triptans 15 days/month asks about stopping. What is the preferred approach?
- A) Gradual taper over 3 months
- B) Abrupt withdrawal
- C) Switch to opioids first
- D) Continue current use and add preventive
Answer: B - Abrupt withdrawal is preferred for medication overuse headache, except for opioids. 2
Slide 11: Diagnostic Tools - Headache Diaries and Questionnaires
Instruct patients to maintain a headache diary to track frequency, duration, intensity, and associated factors. 1
Headache diary components: 2
- Pattern and frequency of headaches
- Accompanying symptoms (nausea, photophobia, phonophobia)
- Acute medication use
- Useful for diagnosis and re-evaluation
Screening questionnaires: 2
- ID-Migraine (3 questions): identifies migraine based on nausea, photophobia, and disability
- Migraine Screen Questionnaire (MS-Q, 5 questions): includes frequency, intensity, length, associated symptoms, and disability
Headache calendars (distinct from diaries) record temporal occurrence, medication use, and related events like menstruation. 2
Slide 12: Patient Education and Self-Management
Provide appropriate reassurance and agree on realistic objectives. 2
Essential patient education components: 1
- Identify and avoid personal triggers
- Establish regular sleep patterns
- Understand medication overuse risk
- Maintain headache diary
Common triggers to discuss: 1
- Stress
- Weather changes
- Odors
- Dietary factors
- Sleep pattern disruptions
- Sexual activity
- Hormonal changes
Family history is important: Migraine has a strong genetic component with higher prevalence among first-degree relatives. 2
Suspicion of migraine should be strengthened by family history and onset at or around puberty. 2
Slide 13: Special Populations - Children and Adolescents
Be aware that presentation can differ from migraine in adults. 2
Management considerations: 2
- Parents and schools have important roles in management
- Bed rest alone can be sufficient for some attacks
- Acute treatment: Use ibuprofen
- Preventive treatment: Propranolol, amitriptyline, or topiramate
Slide 14: Special Populations - Pregnancy and Breastfeeding
Use paracetamol (acetaminophen) for acute treatment in pregnant or breastfeeding women. 2
Avoid preventive treatment if possible during pregnancy and breastfeeding. 2
For women with menstrual migraine: specific management strategies may be needed (though evidence details are limited in provided guidelines). 2
Slide 15: Special Populations - Older Adults
Secondary headache, comorbidities, and adverse events are all more likely in older patients. 2
Critical considerations: 2
- Poor evidence base for all drugs in this age group
- Up to 15% of patients ≥65 years with new-onset headaches may have serious pathology: stroke, temporal arteritis, neoplasm, subdural hematoma 4
- Age >50 with new-onset headache is a red flag requiring investigation 1
Temporal arteritis considerations: 4
- Headaches are the most common symptom (60-90% of cases)
- ESR can be normal in 10-36% of patients
- Temporal artery biopsy can be false-negative in 5-44%
Slide 16: Recognizing and Managing Comorbidities
Ensure that comorbidities are identified in patients with migraine, as they can affect treatment choice and outcomes. 2
Common comorbidities: 2
- Anxiety
- Depression
- Sleep disturbances
- Chronic pain conditions (neck and lower back pain)
- Obesity (risk factor for transformation to chronic migraine)
- Cardiovascular events (associated with migraine with aura in women)
Adjust treatments accordingly: 2
- Topiramate for patients with obesity (weight loss effect)
- Amitriptyline for patients with depression or sleep disturbances
- Consider drug interactions and adverse effect profiles
Alleviation of comorbidities can improve migraine outcomes, and vice versa. 2
Slide 17: Evaluating Treatment Response
Use headache calendars to assess effectiveness and adverse events. 2
When outcomes are suboptimal, review: 2
- Diagnosis accuracy
- Treatment strategy appropriateness
- Dosing adequacy
- Patient adherence
When treatment fails, re-evaluate before changing therapy. 2
Allow additional treatment starting at 2-4 hours after initial dose if pain has not improved. 5
Slide 18: Long-Term Follow-Up Strategy
Primary care should be responsible for long-term management of patients with migraine, maintaining stability and reacting to change. 2
Referral back to primary care from specialist: 2
- Should be timely and coordinated
- Accompanied by comprehensive treatment plan
- Can occur once sustained efficacy with preventive therapy for up to 6 months is obtained with no substantial adverse effects
Avoid regular routine contact unless necessary for repeat prescriptions. 2
Emphasize patient education and self-efficacy regarding when return visits are necessary. 2
Slide 19: When to Refer to Specialist
Specialist referral is indicated for: 2
- Patients with chronic migraine
- Cluster headache
- Headache of uncertain diagnosis
- Poor response to preventive strategies
- Migraine with persistent aura
- Headache with associated motor weakness
Maintain open communication between primary care and specialist for optimal patient outcomes. 2
Slide 20: Key Pitfalls to Avoid
Critical errors to prevent:
- Never use opioids for headache treatment 7
- Never ignore red flags - they require urgent evaluation 1
- Never over-image - neuroimaging not needed for typical primary headaches with normal examination 1
- Never allow medication overuse - educate about risks and monitor frequency 2, 1
- Never prescribe triptans without cardiovascular screening 6
- Never use valproate in women of childbearing potential 2
- Never miss secondary headaches - always consider in patients on long-term analgesics with unremitting headache 8
Establish open, honest physician-patient relationship for proper evaluation and management. 9