What is the approach to managing a patient with headache?

Approach to Management of Headache

Begin by immediately screening for red flag features that mandate urgent neuroimaging or emergency referral: sudden-onset severe headache, new neurological deficits, age >50 years with new-onset headache, fever, headache worsened by Valsalva or positional changes, headache awakening patient from sleep, progressive worsening pattern, or abnormal neurological examination. 1, 2

Red Flag Assessment and Emergency 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 mandate immediate neuroimaging with MRI preferred over CT 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
• Fever or signs of infection require consideration of meningitis or encephalitis with urgent lumbar puncture 2
• Headache worsened by Valsalva, cough, or positional changes suggests increased intracranial pressure from mass lesion or Chiari malformation 2

Diagnostic History for Primary Headaches

Once red flags are excluded, obtain specific details to differentiate primary headache types:

• Frequency and duration: Chronic migraine is defined as ≥15 headache days per month for >3 months with ≥8 days having migraine features 1, 2
• Location and quality: Unilateral throbbing suggests migraine, bilateral pressing/tightening suggests tension-type, strictly unilateral with autonomic symptoms suggests cluster headache 2
• Duration of individual attacks: Migraine lasts 4-72 hours, cluster headache lasts 15-180 minutes, tension-type is variable 2
• Document all over-the-counter and prescription medications used and screen for medication overuse, defined as using acute medications >10 days per month 1, 2
• Identify triggers: Stress, weather changes, odors, dietary factors, sleep patterns, sexual activity, and hormonal changes 1

Physical and Neurological Examination

• Perform complete neurological examination to identify any focal signs that would contraindicate primary headache diagnosis, including vital signs, cranial nerve function, mental status changes, and focal neurological signs 1
• Neuroimaging is usually not warranted in patients with normal neurologic examination and no red flags 1

Acute Treatment Strategy

For Mild-to-Moderate Migraine:

• Use NSAIDs or acetaminophen combined with caffeine as first-line therapy 1, 2

For Moderate-to-Severe Migraine:

• Triptans are first-line therapy, but require cardiovascular screening as they are contraindicated in coronary artery disease, uncontrolled hypertension, and stroke history 1, 2, 3
• Perform cardiovascular evaluation in triptan-naive patients who have multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to receiving triptans 3
• Consider administering the first dose in a medically supervised setting with ECG immediately following administration for patients with multiple cardiovascular risk factors who have negative cardiovascular evaluation 3

For Cluster Headache:

• Acute treatment includes subcutaneous sumatriptan 6 mg and 100% oxygen at 12 L/min via non-rebreather mask 2

Preventive Therapy Indications

Initiate preventive therapy if patient has ≥2 headaches per week or meets criteria for chronic migraine. 1, 2

Additional indications include:

• Two or more attacks per month producing disability lasting ≥3 days per month 4
• Contraindication to or failure of acute treatments 4
• Use of abortive medication more than twice per week 4
• Presence of uncommon migraine conditions including hemiplegic migraine, migraine with prolonged aura, or migrainous infarction 4

First-Line Preventive Options:

For Episodic Migraine:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day (β-blockers with established efficacy) 4
• Topiramate (established efficacy in episodic migraine) 4, 1, 2
• Amitriptyline (superior for patients with mixed migraine and tension-type headache) 4
• Valproate, gabapentin 1, 2

For Chronic Migraine:

• OnabotulinumtoxinA is the only FDA-approved therapy for prophylaxis of headache in adults with chronic migraine 4
• Topiramate has evidence in double-blind, placebo-controlled trials for chronic migraine 4

For Cluster Headache:

• Verapamil 360 mg/day with ECG monitoring for PR interval prolongation 2

Medication-Overuse Headache Management

If patient uses acute medications >10 days per month, diagnose medication-overuse headache and initiate preventive therapy immediately while detoxifying by withdrawing overused medications. 1, 2

• Limit simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month 4
• Avoid opioids or butalbital-containing compounds except as rare rescue medication, as they are most likely to cause medication-overuse headache 4, 2
• Ergotamine (not DHE), opiates, triptans, and simple and mixed analgesics containing butalbital, caffeine, or isometheptene are generally thought to cause rebound headache 4

Patient Education and Monitoring

• Instruct patients to maintain a headache diary to track frequency, duration, intensity, and associated factors 1, 2
• Identify and avoid personal triggers 1, 2
• Establish regular sleep patterns to reduce migraine frequency 1, 2
• Provide preemptive education on the risk of developing medication overuse headache 4

Common Pitfalls to Avoid

• Do not routinely order neuroimaging in patients with normal neurologic examination and no red flags, as this increases costs without improving outcomes 1
• Do not prescribe opioids or butalbital compounds as first-line therapy, as they promote medication-overuse headache and reduce quality of life 4, 2
• Do not delay preventive therapy in patients meeting criteria, as this allows progression to chronic daily headache with central sensitization 5
• Do not use β-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) as they are ineffective for migraine prevention 4