What is the assessment and treatment plan for an adult patient with no significant medical history presenting with frontal headaches?

Assessment and Plan for Frontal Headaches

Begin with immediate assessment for red flag features that mandate urgent neuroimaging and specialist evaluation, as these indicate potentially life-threatening secondary causes requiring immediate intervention. 1, 2

Immediate Red Flag Assessment

Evaluate for the following critical features that require urgent imaging (MRI preferred) and possible emergency referral 1, 2:

• Thunderclap onset (sudden, peaking within 1 minute) - suggests subarachnoid hemorrhage 2
• New headache after age 50 - requires urgent assessment for temporal arteritis, mass lesions, or other serious pathology 1, 2
• Progressive worsening pattern over days to weeks - suggests evolving pathology 1, 2
• Headache awakening patient from sleep - may indicate increased intracranial pressure 1, 2
• Worsening with Valsalva maneuver (coughing, straining, bending) - suggests increased intracranial pressure 1, 2
• Focal neurologic signs or abnormal neurologic examination - mandates immediate imaging 3, 1, 2
• Fever or signs of infection - requires urgent evaluation for meningitis or encephalitis 2
• Scalp tenderness or jaw claudication - may indicate giant cell arteritis 1

If any red flags are present, obtain MRI brain with and without contrast immediately and consider emergency department referral. 1, 2

Detailed History for Primary Headache Classification

If no red flags are present, obtain specific diagnostic information 3:

Pain Characteristics

• Location: Unilateral vs bilateral, frontal vs temporal 3
• Character: Throbbing (suggests migraine) vs pressing/tightening (suggests tension-type) 3
• Intensity: Mild, moderate, or severe 3
• Duration: Minutes, hours, or days 3

Associated Symptoms

• Autonomic features: Lacrimation, rhinorrhea, nasal congestion, eyelid edema (suggests trigeminal autonomic cephalalgia) 3
• Nausea or vomiting (suggests migraine) 3
• Photophobia and phonophobia (suggests migraine) 3
• Visual aura: Scintillations, zigzag lines, scotoma (suggests migraine with aura) 3

Frequency and Triggers

• Frequency: Number of headache days per month 3, 1
• Triggers: Stress, foods, weather, odors, missed meals, sleep patterns 3
• Current medication use: Over-the-counter analgesics, frequency of use 3

Neuroimaging Decision

Neuroimaging is NOT necessary if the patient has a normal neurologic examination, features consistent with primary headache disorders, and a long history of similar headaches without pattern change. 1

Obtain MRI brain with and without contrast if: 1, 2

• Any red flag symptoms present
• Abnormal neurologic examination findings
• Atypical headache patterns that don't fit established primary headache criteria
• Headache with atypical features not meeting strict definition of migraine 3

Acute Treatment Plan

First-Line: NSAIDs

Start with NSAIDs as first-line treatment for mild to moderate frontal headaches 3, 1:

• Ibuprofen 400-800 mg orally at headache onset 1
• Naproxen sodium 500-825 mg orally at headache onset 1
• Aspirin 500-1000 mg orally at headache onset 1

Administer as early as possible during an attack to improve efficacy 3. Acetaminophen alone is ineffective for migraine but works in combination with aspirin and caffeine 3.

Second-Line: Triptans

If NSAIDs fail after adequate trial, use migraine-specific triptans 3, 1, 4:

• Sumatriptan 50-100 mg orally 4
• Rizatriptan 5-10 mg orally 3
• Zolmitriptan 2.5-5 mg orally 3
• Naratriptan 2.5 mg orally 3

Contraindications to triptans: Uncontrolled hypertension, cardiovascular disease, basilar or hemiplegic migraine 3, 4.

Antiemetics for Nausea

Add antiemetics if nausea or vomiting present 1:

• Metoclopramide 10 mg orally or IV 1
• Prochlorperazine 10 mg orally or IV 1

Critical Pitfall: Medication Overuse

Monitor analgesic use closely - overuse (>10 days per month) causes medication-overuse headaches 3. Frequent use of ergotamine, opiates, analgesics, and triptans may cause rebound headaches 3. Avoid opioids as routine headache therapy due to dependency risk, rebound headaches, and limited efficacy 1.

Preventive Therapy Indications

Start preventive therapy if the patient has ≥2 attacks per month producing disability lasting ≥3 days, or if acute treatment is required >2 days per week 3, 1, 2.

First-Line Preventive Options

Choose based on comorbidities 3, 1:

• Propranolol 80-240 mg/day - first choice if no contraindications 3, 1
• Timolol 20-30 mg/day - alternative beta-blocker 3
• Amitriptyline 30-150 mg/day at night - particularly effective for mixed migraine and tension-type headache 3, 1
• Topiramate 50-100 mg/day - effective for chronic migraine 3, 1
• Divalproex sodium 500-1500 mg/day - particularly effective for prolonged or atypical migraine aura 3

Start at low doses and titrate slowly over 2-3 months to assess efficacy 1. Common adverse effects include dizziness, nausea, fatigue with beta-blockers 3; weight gain, drowsiness, anticholinergic symptoms with tricyclics 3; and hair loss, tremor, weight gain with valproate 3.

Second-Line and Specialist Options

For chronic migraine (≥15 headache days per month for >3 months), consider 3, 1, 2:

• OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks - only FDA-approved therapy for chronic migraine prophylaxis 3, 2
• CGRP monoclonal antibodies (erenumab 70-140 mg subcutaneous monthly, fremanezumab 225 mg monthly or 675 mg quarterly) - typically require specialist initiation 3

Follow-Up and Monitoring

Track frequency, severity, triggers, and medication use with a headache diary 1. Evaluate treatment response within 2-3 months after initiation or change in treatment 3, 1.

Key outcome measures 3:

• Attack frequency (headache days per month)
• Attack severity (pain intensity)
• Migraine-related disability

Consider tapering preventive therapy after a period of stability 1.

Specialist Referral Indications

Refer to neurology for 1, 2, 5:

• Cluster headaches - require complex treatment 5
• Chronic migraine (≥15 headache days per month) - may benefit from specialized treatments 2, 5
• Headache with motor weakness (hemiplegic migraine) - requires neurological evaluation 2, 5
• Uncertain diagnosis after thorough primary care evaluation 5
• Poor response to preventive strategies after adequate trials 5
• Persistent aura - may indicate complications 5