What is the appropriate initial management for an adult patient with a complaint of headache and no significant medical history or red flags?

Initial Management of Adult Headache Without Red Flags

For an adult presenting with headache and no significant medical history or red flags, begin with a detailed clinical history to differentiate between primary headache disorders (most commonly migraine or tension-type headache), followed by a targeted physical and neurologic examination—neuroimaging is not warranted if the examination is normal and the headache meets criteria for a primary headache disorder. 1

Step 1: Screen for Red Flags Requiring Urgent Evaluation

Before proceeding with primary headache management, systematically exclude secondary causes by asking about: 1, 2, 3

• Thunderclap onset (subarachnoid hemorrhage)
• Headache worsened by Valsalva maneuver (increased intracranial pressure)
• Awakening from sleep (mass lesion, though less concerning than other red flags)
• New onset in patient >50 years old (giant cell arteritis, mass lesion)
• Progressive worsening pattern (mass lesion, subdural hematoma)
• Fever or systemic symptoms (meningitis, encephalitis)
• Neurologic deficits on examination (stroke, mass lesion)
• Recent head/neck trauma (subdural hematoma, dissection)

If any red flags are present, obtain immediate neuroimaging (CT for acute presentations, MRI for subacute) and consider lumbar puncture if subarachnoid hemorrhage is suspected with negative CT. 1, 2, 3

Step 2: Obtain Focused Headache History

Ask specific questions to characterize the headache pattern: 1, 4

• Frequency and duration: How many headache days per month? Do episodes last 4-72 hours? (suggests migraine if yes)
• Location: Unilateral or bilateral? (unilateral suggests migraine)
• Quality: Pulsating/throbbing (migraine) vs. pressing/tightening (tension-type)?
• Intensity: Moderate-to-severe pain that limits function (migraine) vs. mild-to-moderate (tension-type)?
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia? (presence of ≥1 suggests migraine)
• Aggravating factors: Worsened by routine physical activity? (suggests migraine)
• Medication use: Frequency of analgesic, NSAID, or triptan use (>15 days/month for simple analgesics or >10 days/month for triptans/opioids suggests medication-overuse headache)

A diagnosis of migraine requires ≥5 episodes lasting 4-72 hours with ≥2 pain characteristics (unilateral, pulsating, moderate-to-severe intensity, aggravation by activity) plus ≥1 associated symptom (nausea/vomiting, photophobia, or phonophobia). 4, 5

Step 3: Perform Targeted Physical Examination

Conduct a focused neurologic examination including: 1, 3

• Mental status and cranial nerve examination
• Motor strength, sensation, reflexes, and coordination
• Fundoscopic examination (papilledema suggests increased intracranial pressure)
• Neck stiffness assessment (meningeal irritation)
• Temporal artery palpation if age >50 (tenderness suggests giant cell arteritis)

Patients with a normal neurologic examination and headache meeting criteria for a primary headache disorder do not require neuroimaging. 1, 3

Step 4: Initiate Acute Treatment Based on Severity

For Mild-to-Moderate Headache:

Start with over-the-counter NSAIDs as first-line therapy: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 900-1000 mg. 1, 6

• Acetaminophen alone is less effective but can be used in combination with aspirin and caffeine 1
• Administer medication as early as possible during the attack to improve efficacy 1
• Avoid acetaminophen monotherapy for migraine as it has not been shown to be beneficial 1

For Moderate-to-Severe Headache or Failed NSAID Response:

Prescribe a triptan as second-line therapy if NSAIDs fail after 3 consecutive attacks. 1, 6

• Options include sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg orally 1
• Triptans are most effective when taken early in the attack while headache is still mild 1
• Contraindications include coronary artery disease, uncontrolled hypertension, hemiplegic/basilar migraine, and pregnancy 1, 5
• If one triptan fails, others may still provide relief 1

A critical pitfall: Warn patients to limit acute medication use to <2 days per week to prevent medication-overuse headache. 1

Step 5: Determine Need for Preventive Therapy

Initiate preventive therapy if the patient has ≥2 headaches per month causing disability despite optimized acute treatment, or if using acute medications >2 days per week. 1, 6

First-line preventive options include: 1, 6, 5

• Propranolol 80-160 mg daily or metoprolol (beta-blockers)
• Topiramate 25-100 mg daily (start 25 mg, titrate weekly to 50 mg twice daily)
• Amitriptyline 25-150 mg at bedtime (tricyclic antidepressant)

Counsel women that topiramate reduces oral contraceptive efficacy and has teratogenic risks. 1

Step 6: Provide Patient Education and Follow-Up

Instruct the patient to: 1, 6

• Keep a headache diary documenting frequency, duration, intensity, triggers, and medication use
• Identify and avoid triggers (stress, sleep deprivation, missed meals, specific foods)
• Implement lifestyle modifications (regular sleep schedule, adequate hydration, regular meals, exercise)
• Understand medication-overuse headache risk with frequent analgesic use

Schedule re-evaluation in 2-3 months to assess treatment response, headache frequency, and need for preventive therapy adjustment. 6

Refer to neurology if: atypical features persist despite negative workup, attacks become more frequent/severe, poor response to first-line treatments, or diagnostic uncertainty remains. 6