What is the recommended approach for grading and managing headaches?

Grading and Managing Headaches

Classification Framework

Use the International Classification of Headache Disorders (ICHD-3) criteria to systematically classify headaches as primary (migraine, tension-type, cluster) or secondary (caused by underlying pathology). 1

Primary Headache Diagnostic Criteria

Migraine without aura:

• Requires ≥5 attacks lasting 4-72 hours 1
• Must have at least 2 of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity 1
• Must have at least 1 of: nausea/vomiting, photophobia and phonophobia 1

Migraine with aura:

• Requires ≥2 attacks with fully reversible visual, sensory, speech, motor, brainstem, or retinal symptoms 1
• Symptoms spread gradually over ≥5 minutes and last 5-60 minutes 1
• Headache follows within 60 minutes of aura 1

Chronic migraine:

• Headache ≥15 days per month for >3 months 1
• On ≥8 days/month, headache has migraine features 1

Tension-type headache:

• At least 2 of: pressing/tightening (non-pulsatile) character, mild-to-moderate intensity, bilateral location, no aggravation with routine activity 1
• No nausea/vomiting (anorexia acceptable) 1
• No photophobia AND phonophobia together (may have one or the other) 1

Cluster headache:

• Five attacks with frequency of 1-8 attacks per day 1
• Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes 1
• At least 1 ipsilateral autonomic feature: lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema 1

Red Flag Assessment

Screen for these red flags requiring immediate neuroimaging (MRI preferred): 1

• Sudden onset ("thunderclap" headache)
• New onset after age 50
• Neurologic signs or symptoms
• Onset with exertion
• Orthostatic component
• Papilledema
• Progressive headache
• Precipitated by trauma
• Positional headache
• Pregnancy or postpartum
• Painful eye with autonomic features
• Postinfectious
• Pathology of immune system

Medication Overuse Headache Screening

Assess for high-risk factors in this order of relative impact: 2

• Headache frequency ≥7 days/month 2
• Migraine diagnosis 2
• Frequent use of anxiolytics, analgesics (including opioids or nonopioid analgesics) 2

Suspect medication overuse headache when: 1

• Headache ≥15 days per month 1
• Regular overuse of acute medications: ≥10 days/month for triptans, ≥15 days/month for simple analgesics 1

Severity Grading

Grade headache severity using both pain intensity and functional disability: 3

• Lower severity levels: differentiated primarily by pain intensity 3
• Higher severity levels: differentiated by interference with function 3

Use standardized assessment tools:

• Migraine Disability Assessment (MIDAS) for disability measurement 4
• Headache Impact Test (HIT-6) to monitor progress 5
• Headache Disability Inventory (HDI) for quality of life assessment 4

Management Algorithm for Episodic Migraine

Acute Treatment

For episodic migraine (1-14 headache days per month), use stratified-care approach based on disability severity: 2

Mild-to-moderate disability:

• NSAIDs as first-line acute treatment 1
• Add antiemetics as needed 1

Moderate-to-severe disability:

• Triptans as first-line migraine-specific therapy 2, 1
• The stratified-care approach (assigning treatment based on disability severity) is superior to step-care approach (starting with least expensive and progressing) 2

Preventive Treatment Initiation

Initiate preventive therapy when: 5

• Patients are adversely affected on ≥2 days per month despite optimized acute treatment 5

First-line preventive monotherapy options (conditional recommendation, low-certainty evidence): 2

• β-blockers: metoprolol or propranolol 2
• Antiseizure medications: topiramate or valproate 2
• Angiotensin II-receptor blockers: candesartan or telmisartan 2

Second-line preventive options: 5

• Amitriptyline, particularly with comorbid sleep disturbances 5
• Candesartan for patients with hypertension 5

Third-line for refractory cases:

• CGRP monoclonal antibodies: eptinezumab, erenumab, fremanezumab, or galcanezumab 2
• CGRP antagonist-gepants: atogepant or rimegepant 2

Treatment Duration and Monitoring

Assess efficacy after 2-3 months at therapeutic dose 2

Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 5

Management of Chronic Daily Headache

For chronic daily headache (≥15 days per month for ≥3 months): 6

If medication overuse is present:

• Encourage complete cessation of overused medications 6
• Initiate prophylactic treatment simultaneously 1

Pharmacologic prophylaxis options:

• Amitriptyline 6
• Topiramate 6
• Propranolol 6
• Gabapentin 6
• OnabotulinumtoxinA 6

Nonpharmacologic approaches (combine with medication for optimal results): 2

• Relaxation training 2
• Thermal biofeedback combined with relaxation training 2
• Cognitive-behavioral therapy 2
• Acupuncture 2

Referral Criteria

Refer to neurology/headache specialist for: 1

• Diagnostically challenging cases 1
• Difficult to treat cases 1
• Cases with significant comorbidities 1

Critical Pitfalls to Avoid

Avoid chronic use of acute medications: 2

• NSAIDs ≥15 days/month risk medication overuse headache 2
• Triptans ≥10 days/month risk medication overuse headache 2

Do not use oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy, considerable adverse effects, and dependency risk 7

Do not abandon treatment prematurely—efficacy takes weeks to months to establish 7

Neuroimaging is NOT indicated for migraine with typical features and normal neurological examination 1