What is the initial management approach for an adult patient with no significant past medical history presenting with headache?

Initial Management of Headache in Adults

The first priority when evaluating an adult with headache and no significant past medical history is to systematically rule out life-threatening secondary causes using red flag criteria before diagnosing and treating primary headache disorders. 1

Step 1: Screen for Red Flags Requiring Emergency Evaluation

Immediately assess for the following red flags that mandate urgent or emergency department referral 1, 2:

• Thunderclap headache (sudden onset, peaking within 1 second to 1 minute) - requires immediate emergency evaluation to exclude subarachnoid hemorrhage 2
• New-onset headache after age 50 - needs urgent assessment to exclude temporal arteritis, mass lesions, or other serious pathology 1, 2
• Progressive worsening headache over days to weeks - suggests evolving pathology 1, 3
• Headache worsened by Valsalva maneuver (coughing, straining, bending) - suggests increased intracranial pressure 1, 2
• Headache awakening patient from sleep - may indicate increased intracranial pressure or serious secondary cause 2, 3
• Focal neurological symptoms or signs - mandate immediate imaging and specialist evaluation 1, 2
• Unexplained fever with neck stiffness - requires urgent evaluation for meningitis or encephalitis 1, 2
• Recent head or neck trauma 1

If any red flag is present, consider emergency admission or urgent neuroimaging before proceeding with primary headache diagnosis. 1

Step 2: Obtain Focused History

When no red flags are present, obtain the following specific information to differentiate primary headache types 4:

• Age at onset of headache 4
• Duration of individual headache episodes (4-72 hours suggests migraine) 4, 3
• Frequency of headache episodes (≥15 days/month suggests chronic migraine or tension-type headache) 4, 1
• Pain characteristics:
  • Location (unilateral suggests migraine; bilateral suggests tension-type) 4, 1
  • Quality (pulsating suggests migraine; pressing/tightening suggests tension-type) 4, 1
  • Severity (moderate-to-severe suggests migraine; mild-to-moderate suggests tension-type) 4, 1
  • Aggravation by routine physical activity (suggests migraine if present) 4, 1
• Accompanying symptoms:
  • Nausea and/or vomiting (suggests migraine) 4, 1
  • Photophobia and phonophobia (suggests migraine) 4, 1
• Aura symptoms (visual, sensory, speech/language disturbances lasting 5-60 minutes) 4
• Family history of migraine (strengthens suspicion of migraine) 4
• Current and past medication use (≥10 days/month of acute medications suggests medication-overuse headache) 4, 2

Step 3: Perform Thorough Physical and Neurological Examination

A normal neurological examination in a patient with typical primary headache features and no red flags does not require neuroimaging. 3 However, neuroimaging is warranted when there are unexplained abnormal findings on neurologic examination, new onset in patients over 50 years, or atypical features that don't fit established primary headache patterns. 3

Step 4: Diagnose Primary Headache Type

Migraine Without Aura

Suspect migraine without aura when headache is unilateral, pulsating, moderate-to-severe, and accompanied by nausea/vomiting or photophobia plus phonophobia, with duration of 4-72 hours when untreated. 1 Requires at least 5 lifetime attacks meeting these criteria. 4, 1

Migraine With Aura

Requires ≥2 attacks with fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal) that spread gradually over ≥5 minutes, with each symptom lasting 5-60 minutes, and headache accompanying or following within 60 minutes. 4, 1

Tension-Type Headache

Diagnose when headache is bilateral, pressing or tightening quality, mild-to-moderate intensity, and not aggravated by routine physical activity. 1 Lacks nausea/vomiting and has at most one of photophobia or phonophobia. 4

Cluster Headache

Rare but highly characteristic: strictly unilateral orbital/periorbital/temporal pain, severe or very severe intensity, lasting 15-180 minutes, with frequency of 1-8 attacks daily, accompanied by ipsilateral autonomic features (lacrimation, nasal congestion, ptosis, miosis). 4, 1

Step 5: Implement Diagnostic Tools

• Use validated screening questionnaires such as ID-Migraine or Migraine Screen Questionnaire to diagnose migraine 1
• Recommend a headache diary to track frequency, severity, triggers, and treatment response - this is essential for accurate diagnosis and reduces recall bias 1, 3

Step 6: Determine Need for Specialist Referral

Refer to neurology for: 2, 3, 5

• Cluster headaches (complex treatment requirements) 2
• Headache with motor weakness (e.g., hemiplegic migraine) 2, 5
• Migraine with persistent aura 2, 5
• Uncertain diagnosis after thorough primary care evaluation 2, 5
• Poor response to preventive strategies after adequate trials 2, 5
• Chronic migraine (≥15 headache days/month for >3 months with migraine features on ≥8 days) requiring specialized treatments 2

Manage in primary care: 2

• Typical migraine or tension-type headache with normal neurological examination and no red flags 2
• Episodic migraine responding to acute treatment with NSAIDs or triptans 2
• Long history of similar headaches without change in pattern and normal examination 2

Common Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 2
• Recognize medication overuse headache in patients taking analgesics >10 days per month or any other acute medication >10 days/month for >3 months - these patients may need specialist referral for detoxification 4, 2
• Do not order routine neuroimaging for patients with normal neurologic examination, features consistent with primary headache disorders, or long history of similar headaches without change in pattern 3