What is the plan of care for an adult patient with no significant past medical history presenting with headache and nausea?

Plan of Care for Headache and Nausea

Start with NSAIDs (ibuprofen, naproxen, or aspirin) or acetaminophen-aspirin-caffeine combination as first-line treatment for the acute headache, and add an antiemetic for the nausea. 1

Immediate Red Flag Assessment

Before initiating treatment, rapidly screen for life-threatening causes that require emergency imaging or referral:

• Sudden-onset severe headache reaching maximal intensity immediately suggests subarachnoid hemorrhage and requires non-contrast head CT within 6 hours, followed by lumbar puncture if CT is negative 2
• New neurological deficits (focal weakness, vision changes, speech difficulty, altered consciousness) mandate immediate MRI brain 2
• Fever with headache requires consideration of meningitis with urgent lumbar puncture 2
• Age >50 years with new-onset headache increases risk of temporal arteritis, subdural hematoma, or neoplasm to 15% and warrants ESR/CRP testing and neuroimaging 2
• Headache worsened by Valsalva, cough, or positional changes suggests increased intracranial pressure from mass lesion 2

If any red flags are present, do not treat empirically—obtain urgent imaging and specialist consultation immediately. 2

Acute Treatment Algorithm

For Mild to Moderate Headache:

First-line options include aspirin, ibuprofen, naproxen sodium, or the acetaminophen-aspirin-caffeine combination. 1 Acetaminophen alone is ineffective for migraine. 1

• Ensure adequate dosing: Consider increasing the dosage without exceeding the recommended maximum daily dose if initial response is inadequate 1
• For nausea, use a nonoral route of administration when nausea presents early as a significant component, and treat nausea with an antiemetic drug 1

For Moderate to Severe Headache or NSAID Failure:

Add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated. 1

• Triptans with good evidence for efficacy include: naratriptan, rizatriptan, zolmitriptan (oral), and sumatriptan (oral and subcutaneous) 1
• Screen for cardiovascular disease before prescribing triptans—they are contraindicated in uncontrolled hypertension, coronary artery disease, stroke history, basilar or hemiplegic migraine 1, 2
• Choice of specific triptan should be based on patient preferences regarding route of administration and cost 1
• Counsel patients to begin treatment as soon as possible after headache onset, using combination therapy (triptan with NSAID or acetaminophen) to improve efficacy 1

For Severe Nausea or Vomiting:

Consider using a nonoral triptan (subcutaneous or intranasal) and an antiemetic. 1

• Intranasal dihydroergotamine has good evidence for efficacy and safety 1

Critical Medications to Avoid

Do not use opioids or butalbital for the treatment of acute episodic migraine. 1

• These agents are most likely to cause medication-overuse headache and should be avoided except as rare rescue medication 2
• Opioids may be considered only if other medications cannot be used, the risk of abuse has been addressed, and sedation is not a concern 1

Medication Overuse Headache Prevention

Limit acute treatment to no more than twice a week to prevent medication overuse headache. 1

• Medication overuse headache is defined as headache occurring on ≥15 days per month for at least 3 months in people with a preexisting headache disorder that develops because of overuse of acute medication 1
• The threshold varies by treatment: ≥15 days per month with NSAIDs; ≥10 days per month with triptans 1

When to Consider Preventive Therapy

If episodic migraine occurs frequently or treatment does not provide adequate response, the addition of preventive medications is warranted. 1

Commonly accepted indications for migraine prevention include:

• Two or more migraine attacks per month with disability for three or more days per month 1
• Use of rescue medication more than twice a week 1
• Failure of acute treatments or contraindications for such treatments 1

First-line preventive agents include: propranolol 80-240 mg/day, timolol 20-30 mg/day, amitriptyline 30-150 mg/day, divalproex sodium 500-1,500 mg/day, or sodium valproate 800-1,500 mg/day. 1

Lifestyle Modifications

Emphasize the importance of staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity (preferably moderate to intense aerobic exercise), managing stress with relaxation techniques or mindfulness practices, and pursuing weight loss for those who are overweight or obese. 1

• Explore modifiable migraine triggers during a detailed history 1
• Maintain a headache diary to guide management decisions and identify personal triggers 2

Special Populations

In people of childbearing potential and in those who are pregnant or breastfeeding, discuss the adverse effects of pharmacologic treatments during pregnancy and lactation before prescribing. 1