What is the approach to a patient presenting with headache?

Approach to Patient with Headache

The initial evaluation of any patient presenting with headache must prioritize ruling out secondary causes through careful assessment for "red flags" before diagnosing and managing primary headache disorders. 1, 2

Step 1: Screen for Red Flags Requiring Urgent Evaluation

Immediately identify features that mandate emergency department referral or urgent imaging:

• Thunderclap headache (sudden onset, peaking within 1 second to 1 minute) - suggests subarachnoid hemorrhage 2
• New headache after age 50 - requires urgent assessment for temporal arteritis, mass lesions, or other serious pathology 2, 3
• Headache worsened by Valsalva maneuver (coughing, straining, bending) - suggests increased intracranial pressure 2, 3
• Headache awakening patient from sleep - may indicate increased intracranial pressure or serious secondary cause 2, 3
• Progressively worsening headache over days to weeks - suggests evolving pathology 2, 3
• Fever or signs of infection with headache - requires urgent evaluation for meningitis or encephalitis 2
• Abnormal neurological examination findings - mandate immediate imaging and specialist evaluation 2, 3
• Focal neurological deficits or motor weakness - necessitate neurological evaluation to exclude serious secondary causes 2, 4

Step 2: Obtain Focused History

If no red flags are present, obtain specific details to characterize the headache:

• Frequency: Ask directly "Do you feel like you have a headache of some type on 15 or more days per month?" to identify chronic patterns 1
• Duration: Determine if headaches last 15-180 minutes (cluster), 4-72 hours (migraine), or are continuous (chronic daily headache) 4, 3
• Location: Unilateral pain suggests migraine or cluster headache; bilateral suggests tension-type 4
• Character: Pulsating quality suggests migraine; pressing/tightening suggests tension-type 4
• Associated symptoms: Photophobia, phonophobia, nausea/vomiting suggest migraine; ipsilateral autonomic symptoms (lacrimation, rhinorrhea, ptosis) suggest cluster headache 4
• Behavior during attack: Patients preferring to lie still suggest migraine; pacing or restlessness suggests cluster headache 4
• Medication use: Document analgesic use frequency - more than 10 days per month indicates risk for medication overuse headache 2, 5

Common pitfall: Patients typically report only their "severe headache days" and fail to mention milder headaches, leading to underdiagnosis of chronic patterns. 1

Step 3: Perform Neurological Examination

A complete neurological examination is essential - if normal, neuroimaging is generally not warranted for patients with features consistent with primary headache disorders and no red flags. 3, 6

Step 4: Determine Need for Neuroimaging

Neuroimaging is indicated when:

• Any red flags are present 2, 3
• Unexplained abnormal findings on neurologic examination 3
• Atypical features that don't fit established primary headache patterns 3

Neuroimaging is NOT warranted when:

• Normal neurologic examination with features consistent with primary headache disorders 3
• Long history of similar headaches without change in pattern 2, 3

MRI brain is the preferred imaging modality when indicated. 4

Step 5: Classify Primary Headache Disorder

If secondary causes are excluded, assess for primary headache types:

Chronic Migraine (≥15 headache days/month)

• Diagnostic criteria: 15 or more headaches per month, each at least 4 hours in duration, with migraine features on 8 or more days per month 1, 3
• Treatment approach: Both prophylactic treatment and as-needed treatment for exacerbations 1
• Prophylactic options: Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 1
• FDA-approved therapy: OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis 1, 3
• Referral: Should be referred for specialist management, as these patients may benefit from specialized treatments including onabotulinumtoxinA or CGRP monoclonal antibodies 2

Episodic Migraine (<15 headache days/month)

• Acute treatment: NSAIDs, acetaminophen, or triptans for acute episodes 7
• Prophylaxis indication: Consider if headaches occur more than twice weekly 3
• Evidence-based prophylactic options: Topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, valproate 1, 3
• Can be managed in primary care if responding to treatment 2

Cluster Headache

• Diagnostic features: Severe unilateral pain lasting 15-180 minutes with ipsilateral autonomic symptoms, occurring 1-8 times daily in clusters 4
• Distinguishing feature: Patients pace or are restless during attacks (unlike migraine where patients lie still) 4
• Referral: All cluster headache patients should be referred to neurology due to complex treatment requirements 2, 5

Tension-Type Headache

• Features: Bilateral, pressing/tightening quality, mild to moderate intensity, lacks autonomic features 4
• Can be managed in primary care with analgesics and lifestyle modifications 2

Step 6: Identify Modifiable Risk Factors

Help patients identify and manage triggers:

• Obesity, medication overuse, caffeine use, obstructive sleep apnea, psychiatric comorbidities, stress 1
• Recommend headache diary to track frequency, severity, triggers, and treatment response 3

Step 7: Determine Need for Specialist Referral

Refer to neurology for:

• All cluster headaches 2, 5
• Chronic migraine (≥15 headache days/month) 2
• Headache with motor weakness (e.g., hemiplegic migraine) 2, 5
• Migraine with persistent aura 2, 5
• Uncertain diagnosis after thorough primary care evaluation 2, 5
• Poor response to preventive strategies after adequate trials 2, 5
• Medication overuse headache requiring detoxification 2

Maintain in primary care:

• Typical migraine or tension-type headache with normal examination and no red flags 2
• Episodic migraine responding to acute treatment 2
• Stable, well-controlled headaches with regular monitoring 2

Critical Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 2
• Recognize medication overuse headache in patients taking analgesics more than 10 days per month - these patients may need specialist referral for detoxification 2
• Avoid opioids for regular headache management due to risk of dependency and rebound headaches 3
• Screen cardiovascular risk factors before prescribing triptans due to vasoconstrictive properties 4, 7
• React promptly to any change in headache pattern that may warrant re-referral even in previously stable patients 2