What is the appropriate initial assessment and treatment for a patient presenting with a headache?

Initial Assessment and Management of Headache

Begin by systematically screening for "red flags" that indicate life-threatening secondary causes requiring immediate imaging and emergency evaluation, then classify the headache type through focused history to guide acute treatment and determine need for preventive therapy. 1, 2

Immediate Red Flag Assessment

Your first priority is identifying dangerous secondary headaches that require urgent intervention. Screen for these specific features 1, 2, 3:

• Thunderclap onset (sudden, maximal intensity within seconds to minutes) 3
• Headache awakening patient from sleep 1, 2
• Worsening with Valsalva maneuver (coughing, straining, bending) 1
• Progressive worsening pattern over days to weeks 1
• Focal neurologic deficits (weakness, sensory loss, visual field cuts) 2
• Altered consciousness or confusion 2
• Fever or signs of infection 1
• New onset after age 50 years 1
• History of cancer or immunosuppression 4
• Papilledema on fundoscopic exam 3

If any red flags are present, obtain non-contrast head CT immediately to exclude intracranial hemorrhage or mass effect, followed by lumbar puncture if CT is normal to rule out subarachnoid hemorrhage. 3

Focused History for Primary Headache Classification

When red flags are absent and neurologic examination is normal, obtain these specific details to classify the primary headache 5:

Temporal Pattern

• Frequency: Number of headache days per month 5
• Duration: How long each episode lasts (4-72 hours suggests migraine) 5
• Age at onset: Onset at or around puberty strengthens migraine diagnosis 5

Pain Characteristics

• Location: Unilateral (suggests migraine) vs bilateral 5
• Quality: Pulsating/throbbing (suggests migraine) vs pressure-like 5
• Intensity: Moderate to severe pain that limits activity (suggests migraine) 5
• Aggravation: Worsened by routine physical activity like walking or climbing stairs 5

Associated Symptoms

• Nausea and/or vomiting 5
• Photophobia and phonophobia (light and sound sensitivity) 5
• Aura symptoms: Visual disturbances, sensory changes, speech difficulties lasting 5-60 minutes 5
• Cranial autonomic symptoms: Rhinorrhea, lacrimation (common in pediatric migraine, often misdiagnosed as "sinus headache") 5

Critical Medication History

• Current acute medication use: Document frequency per month 5
• Screen for medication overuse headache: ≥15 days/month of simple analgesics OR ≥10 days/month of triptans/combination analgesics for >3 months 5, 6

Family History

• First-degree relatives with migraine strongly supports migraine diagnosis 5

Neuroimaging Decision Framework

Do NOT obtain neuroimaging if the patient has a normal neurologic examination, features consistent with primary headache, and no red flags. 1, 2 This is a common pitfall—unnecessary imaging in primary headache wastes resources and may lead to incidental findings causing patient anxiety.

Obtain MRI brain (preferred over CT for non-emergent evaluation) only when: 1

• Unexplained abnormal findings on neurologic examination
• New onset headache in patient over 50 years
• Atypical features that don't fit established primary headache patterns
• Progressive worsening despite appropriate treatment

Acute Treatment Algorithm

For Moderate to Severe Migraine

First-line acute treatment is combination therapy with IV metoclopramide 10mg plus IV ketorolac 30mg for severe presentations requiring emergency care. 2 This provides rapid pain relief with synergistic analgesia.

For outpatient management, prescribe triptans (e.g., sumatriptan 50-100mg) to be taken early when headache is still mild. 2, 7 Key points:

• Sumatriptan 50mg and 100mg achieve headache response (reduction to mild or no pain) in 61-62% at 2 hours and 78-79% at 4 hours, compared to 27% and 38% with placebo 7
• Avoid triptans in patients with cardiovascular disease due to vasoconstrictive properties 4
• Alternative options include gepants (rimegepant, ubrogepant) which eliminate headache in 20% at 2 hours with minimal cardiovascular risk 4

Absolutely avoid opioids for routine headache management due to dependency risk and rebound headaches. 2

Preventive Therapy Indications

Initiate preventive therapy when headaches impair quality of life on ≥2 days per month despite optimized acute therapy, OR when acute medications are used >2 days per week. 2, 6 Do not wait for an arbitrary threshold—focus on functional impairment.

First-Line Preventive Options

For chronic migraine (≥15 headache days/month for >3 months with migraine features on ≥8 days), prescribe CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) as monthly subcutaneous injections. 6 These reduce migraine days by 2-4.8 days per month with favorable tolerability.

Monitor blood pressure with erenumab due to postmarketing reports of hypertension. 6

Second-Line Options

• Topiramate: Start 25mg daily, titrate slowly to 100-200mg daily; warn about cognitive slowing, paresthesias, weight loss, kidney stones 6
• OnabotulinumtoxinA: FDA-approved for chronic migraine 1, 6

Set realistic expectations: preventive therapy takes 2-3 months to show full benefit, and the goal is control (reducing frequency/severity), not cure. 2

Mandatory Patient Education

• Maintain headache diary tracking frequency, severity, triggers, and treatment response 1
• Identify and avoid personal triggers (irregular sleep, missed meals, dehydration, stress) 2
• Avoid medication overuse: Limit simple analgesics to <15 days/month and triptans to <10 days/month 5, 6

Referral to Neurology

Refer immediately for: 1, 8

• Cluster headaches
• Uncertain diagnosis despite thorough evaluation
• Poor response to preventive strategies
• Migraine with persistent aura
• Headache with motor weakness