What is the best course of action for a 30-year-old female patient with no specified medical history presenting with headaches?

Evaluation and Management of Headaches in a 30-Year-Old Female

Begin with a thorough characterization of the headache pattern, focusing on red flag features, then proceed with targeted evaluation based on the clinical presentation—most headaches in this age group are primary headache disorders (migraine or tension-type), but any concerning features mandate immediate neuroimaging.

Initial Clinical Assessment

Critical Red Flags Requiring Immediate Neuroimaging

• Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds to minutes) 1, 2
• Progressive worsening pattern over days to weeks 3, 1
• Headache awakening patient from sleep 3, 1
• Worsening with Valsalva maneuver (coughing, straining, bending) 3, 1
• Any focal neurologic deficits on examination 3, 2
• Fever or systemic symptoms suggesting infection 1, 2
• Recent head or neck trauma 1

Essential History Elements

• Duration of individual episodes: 4-72 hours suggests migraine 4, 5
• Pain characteristics: Unilateral, pulsating quality, moderate-to-severe intensity, aggravated by routine physical activity strongly suggests migraine 4, 5
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia support migraine diagnosis 4, 5
• Frequency of analgesic use: Document all over-the-counter and prescription pain medications to identify medication-overuse headache (use ≥10-15 days per month) 6
• Family history: Positive family history of migraine increases likelihood 2

Physical Examination

• Complete neurologic examination is mandatory—any abnormality requires immediate imaging 3, 1
• Fundoscopic examination to assess for papilledema 2
• Focused head and neck examination including temporal artery palpation (though temporal arteritis is rare at age 30) 6

Diagnostic Testing Strategy

When Neuroimaging is NOT Required

• Normal neurologic examination AND no red flags AND headache pattern consistent with primary headache disorder (migraine or tension-type) 2
• Chronic, recurrent headaches with stable pattern and normal examination have very low yield (0.2-0.5%) for significant abnormalities 7

When Neuroimaging IS Required

• Any red flag present as listed above 3, 1, 2
• MRI of the brain without contrast is the preferred modality for non-emergent evaluation 3, 7
• Non-contrast CT of the head only if thunderclap headache (to rule out subarachnoid hemorrhage) or MRI unavailable 3, 2

Laboratory Testing

• Generally not indicated in straightforward primary headache with normal examination 7
• Consider basic metabolic panel (glucose, sodium) only if clinical suspicion for metabolic derangement 7
• ESR and CRP not needed in a 30-year-old without temporal arteritis symptoms 3

Lumbar Puncture Indications

• Thunderclap headache with negative CT (perform >6 hours from onset to assess for xanthochromia) 3
• Suspected meningitis or encephalitis 1

Management Based on Diagnosis

If Migraine is Diagnosed (Most Likely in This Age Group)

Acute Treatment

• First-line: NSAIDs (ibuprofen 400-800mg, naproxen 500-1000mg) or acetaminophen 1000mg 5, 8
• Second-line: Triptans (e.g., sumatriptan 50-100mg orally) if NSAIDs fail—eliminates pain in 20-30% at 2 hours 5
  • Contraindications: Uncontrolled hypertension, cardiovascular disease, hemiplegic or basilar migraine 9
  • Common adverse effects include transient flushing, tightness, tingling in 25% 5
• Alternative: Gepants (rimegepant, ubrogepant) or lasmiditan for patients with cardiovascular risk factors 5
• Antiemetics: Metoclopramide IV for patients with prominent nausea/vomiting 9

Critical Medication Overuse Prevention

• Limit acute therapy to ≤2 days per week to prevent medication-overuse headache 9
• Do not start daily analgesics without establishing diagnosis 3

Preventive Therapy Indications

• Offer if: ≥4 headache days per month causing significant disability 6
• First-line options: Propranolol, timolol, amitriptyline, or divalproex sodium 3
• Expected benefit: Reduction of 1-3 migraine days per month compared to placebo 5

If Tension-Type Headache is Diagnosed

• Acute treatment: NSAIDs or acetaminophen 8
• Preventive therapy: Consider if frequent (≥15 days per month) 6

Common Pitfalls to Avoid

• Do not assume primary headache disorder without thorough red flag assessment 3, 1
• Do not order routine laboratory tests in patients with typical primary headache and normal examination 7
• Do not overlook medication overuse—specifically ask about all analgesics, including those obtained from others 6
• Do not use opioids as first-line therapy—reserve only when other medications contraindicated and abuse risk addressed 9

Follow-Up Strategy

• Headache diary: Have patient document frequency, duration, intensity, triggers, and medication use 6
• Scheduled follow-up to monitor treatment response and adjust therapy 6
• Neurology referral if: atypical features despite negative workup, refractory to initial management, or chronic daily headache requiring complex prophylaxis 3