What is the appropriate management for a patient presenting with a headache?

Management of Acute Headache

For patients presenting with headache, immediately rule out life-threatening secondary causes through focused history and neurological examination, then treat primary headaches with NSAIDs or triptans based on severity, while strictly limiting acute medications to twice weekly to prevent medication-overuse headache. 1

Initial Assessment: Rule Out Red Flags

The cornerstone is distinguishing secondary (potentially life-threatening) from primary (benign) headaches through targeted clinical evaluation 2, 3:

Critical red flags requiring immediate investigation:

• Thunderclap onset (pain peaking within seconds to 1 minute) suggesting subarachnoid hemorrhage 4
• Age ≥40 years at first presentation 4
• Witnessed loss of consciousness 4
• Onset during exertion 4
• Neck pain, stiffness, or limited neck flexion 4
• Fever with altered mental status (meningitis) 5
• Focal neurological deficits, papilledema, or ataxia 5
• Progressive worsening over days to weeks 3
• Headache awakening patient from sleep 6

Key historical features distinguishing subarachnoid hemorrhage:

• Occipital location 4
• Stabbing quality 4
• Presence of meningismus 4

Neuroimaging indications: CT scan is warranted for any red flag features; if negative but subarachnoid hemorrhage suspected, proceed to lumbar puncture 6, 5

Treatment Algorithm for Primary Headache

Mild to Moderate Headache

First-line therapy: NSAIDs 6, 1

• Naproxen sodium 500-825 mg at onset, repeat every 2-6 hours (maximum 1.5 g/day) 1
• Ibuprofen 400-800 mg 1
• Aspirin 1000 mg 1
• Combination therapy: aspirin + acetaminophen + caffeine for enhanced efficacy 6, 1

Adjunctive antiemetic (if nausea present):

• Metoclopramide 10 mg PO/IV provides synergistic analgesia beyond antiemetic effects through central dopamine antagonism 1
• Prochlorperazine 10-25 mg 1

Moderate to Severe Headache

Combination therapy is superior to monotherapy: 1

• Triptan (sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan) PLUS naproxen sodium 500 mg 6, 1
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1

For rapid progression or severe vomiting:

• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% complete pain-free at 2 hours) with onset within 15 minutes 1
• Intranasal sumatriptan 5-20 mg as alternative 1

Parenteral Therapy (Emergency Department/Urgent Care)

Optimal IV "headache cocktail": 1

• Metoclopramide 10 mg IV (provides direct analgesic effects) 1
• PLUS Ketorolac 30 mg IV (rapid onset, 6-hour duration, minimal rebound risk) 1
• Alternative: Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide with favorable side effect profile) 1

Second-line IV option:

• Dihydroergotamine (DHE) IV or intranasal has good evidence as monotherapy 1

Contraindications to triptans: Ischemic heart disease, uncontrolled hypertension, vasospastic coronary disease, or significant cardiovascular disease 1

Critical Medication Frequency Limits

Limit ALL acute medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1. This applies to:

• NSAIDs (≥15 days/month triggers medication-overuse headache) 1
• Triptans (≥10 days/month triggers medication-overuse headache) 1
• Combination analgesics 1

When Acute Treatment Fails

Initiate preventive therapy immediately if: 1

• Headaches occur ≥2 times per week requiring acute treatment 1
• Two or more attacks per month producing disability lasting ≥3 days 1
• Patient has failed adequate trials of acute medications 1

First-line preventive medications: 1

• Propranolol 80-240 mg/day 1
• Topiramate 1
• Amitriptyline 30-150 mg/day (especially for mixed migraine/tension-type) 1

Medications to Avoid

Opioids (including hydromorphone, oxycodone) should be avoided as they lead to dependency, rebound headaches, medication-overuse headache, and have limited efficacy for headache treatment 6, 1, 2. Reserve only for cases where all other options are contraindicated and abuse risk has been addressed 1.

Butalbital-containing compounds similarly cause medication-overuse headache and dependency 1.

Common Pitfalls

• Do not allow patients to increase frequency of acute medication use in response to treatment failure; this creates a vicious cycle of medication-overuse headache 1
• Do not miss medication-overuse headache as the cause of treatment failure; assess frequency of acute medication use 1
• Do not delay preventive therapy when patients require acute treatment more than twice weekly 1
• Take medication early in the attack while pain is still mild for maximum effectiveness 1
• Failure of one triptan does not predict failure of others; try different triptans before escalating 1