What is the recommended management for an adult patient with no significant medical history presenting with a headache?

Headache Management in Adults

Initial Evaluation: Rule Out Red Flags First

Begin by systematically screening for dangerous secondary causes using red flag symptoms before assuming a benign primary headache disorder. 1

Critical red flags requiring immediate neuroimaging and urgent evaluation include:

• Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds to minutes) 2, 1
• New headache after age 50 2, 1
• Progressive worsening pattern over days to weeks 2, 1
• Headache awakening patient from sleep 2, 1
• Worsening with Valsalva maneuver (coughing, straining, bending) 2, 1
• Fever or signs of infection 1
• Focal neurologic signs or symptoms 3
• Scalp tenderness, jaw claudication (suspect giant cell arteritis in patients >50) 2

Essential History Components

Ask these specific diagnostic questions to classify the headache type:

• Location: Unilateral suggests migraine or cluster; bilateral suggests tension-type 3
• Character: Throbbing/pulsatile suggests migraine; pressing/tightening suggests tension-type 3
• Intensity: Moderate-to-severe suggests migraine; mild-to-moderate suggests tension-type 3
• Duration: 15-180 minutes suggests cluster; 4-72 hours suggests migraine 3
• Associated symptoms: Nausea/vomiting, photophobia/phonophobia suggest migraine; lacrimation, nasal congestion, ptosis suggest cluster 3
• Aggravating factors: Worsening with routine activity suggests migraine; no aggravation suggests tension-type 3
• Medication use: Document ALL analgesics including over-the-counter medications to identify medication overuse headache (≥15 days/month for NSAIDs or ≥10 days/month for triptans/opioids) 4, 1

Physical and Neurologic Examination

Perform a focused neurologic examination emphasizing:

• Mental status assessment 2
• Cranial nerve function (especially visual fields, pupillary responses, extraocular movements) 2
• Motor and sensory function 2
• Fundoscopic examination for papilledema 2
• Blood pressure measurement 2
• Palpation of temporal arteries for tenderness (giant cell arteritis) 2

Neuroimaging Decision Algorithm

Do NOT order neuroimaging if: The patient has a normal neurologic examination, features consistent with primary headache disorders (migraine, tension-type, cluster), and a long history of similar headaches without pattern change 1

DO order MRI with and without contrast if:

• Any red flag symptoms present 2, 1
• Abnormal neurologic examination findings 3, 1
• Atypical headache patterns that don't fit established primary headache criteria 3, 1
• Rapidly increasing frequency of headaches 3
• History of uncoordination 3
• Persistent headache following head trauma 3

Acute Treatment Strategy

For Migraine or Tension-Type Headache:

First-line: NSAIDs 3, 5

• Ibuprofen 400-800 mg at headache onset 6, 5
• Naproxen sodium 500-825 mg at headache onset 3, 6
• Aspirin 500-1000 mg 3, 6
• Combination: Acetaminophen + aspirin + caffeine 3

Second-line: Triptans (if NSAIDs fail after adequate trial) 3, 5

• Oral sumatriptan, rizatriptan, zolmitriptan, or naratriptan 3
• Subcutaneous sumatriptan for rapid onset 3
• Contraindicated in cardiovascular disease due to vasoconstrictive properties 5

Alternative second-line: Gepants (rimegepant, ubrogepant) 5

• Safe in patients with cardiovascular risk factors 5
• Eliminate headache in 20% at 2 hours 5
• Adverse effects: nausea, dry mouth (1-4% of patients) 5

For nausea/vomiting: Treat with antiemetics (metoclopramide 10 mg or prochlorperazine 10 mg) regardless of vomiting presence, as nausea itself is disabling 3, 6

Critical pitfall: Limit acute medications to no more than 2 days per week to prevent medication overuse headache 6, 1

When to Initiate Preventive Therapy

Start preventive therapy if any of the following apply:

• ≥2 attacks per month producing disability lasting ≥3 days 3
• Acute treatment required >2 days per week 6, 1
• Contraindication to or failure of acute treatments 3
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 3

First-Line Preventive Options:

Beta-blockers: 3, 2, 6

• Propranolol 80-240 mg/day
• Timolol 20-30 mg/day
• Metoprolol or atenolol (alternative options)

Antiepileptics: 3, 2, 6

• Topiramate (strong evidence from RCTs)
• Divalproex sodium 500-1500 mg/day
• Sodium valproate 800-1500 mg/day

Tricyclic antidepressants: 3

• Amitriptyline 30-150 mg/day

For chronic migraine (≥15 headache days/month for >3 months): OnabotulinumtoxinA is FDA-approved 1

Special Considerations

Medication overuse headache management:

• Suspect in any patient with frequent headaches using acute medications regularly 4
• Opiates, barbiturates, benzodiazepines require slow tapering (possibly inpatient) to prevent acute withdrawal 4
• Other agents (NSAIDs, triptans) can be withdrawn more quickly 4
• Address underlying headache disorder simultaneously with preventive therapy 4

Avoid these pitfalls:

• Never use opioids as routine headache therapy due to dependency risk, rebound headaches, and limited efficacy 1, 4
• Avoid triptans in patients with cardiovascular disease 5
• Start preventive medications at low doses and titrate slowly over 2-3 months to assess efficacy 3, 2

Follow-Up and Monitoring

• Headache diary: Track frequency, severity, triggers, and medication use 1
• Evaluate treatment response within 2-3 months 2
• Consider tapering preventive therapy after period of stability 3
• Refer to neurology for: cluster headaches, uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with motor weakness 1