What is the initial management approach for a patient presenting with headaches, considering their medical history and potential for migraines or other underlying conditions?

Initial Management of Headache

For most patients presenting with headaches, begin with NSAIDs (aspirin, ibuprofen, or naproxen) as first-line acute treatment, while simultaneously ruling out secondary causes through targeted history and immediate neuroimaging if any red flags are present. 1, 2

Immediate Risk Stratification

Determine if red flags are present that mandate emergent evaluation:

• Thunderclap headache (sudden, severe onset) 2
• New-onset headache after age 50 2
• Neurologic deficits on examination 2
• Headache worsened by Valsalva maneuver 2
• Headache awakening patient from sleep 2
• Progressively worsening pattern 2

If any red flag is present, obtain MRI of the brain immediately (preferred over CT for detecting tumors, stroke, and structural lesions), and do not initiate treatment until secondary causes are excluded. 2

For patients over 50 with new headache, measure ESR and CRP immediately to exclude temporal arteritis before starting any treatment, as this can prevent permanent vision loss. 2

Acute Treatment Algorithm

First-Line: NSAIDs

Start with NSAIDs for most migraine sufferers as first-line therapy: 1

• Ibuprofen 400 mg provides 2-hour headache relief in 57% of patients (NNT 3.2) and is more effective than 200 mg 3
• Aspirin-acetaminophen-caffeine combination (strong recommendation) provides pain freedom at 2 hours with NNT of 9 1
• Naproxen sodium is also effective as first-line 1

Critical caveat: Use of pain relievers more than twice weekly places patients at risk for medication-overuse headache. 4

Second-Line: Migraine-Specific Agents

If NSAIDs fail after 2 hours, escalate to triptans or gepants: 1

Triptans (for patients without cardiovascular disease):

• Sumatriptan 50-100 mg orally provides 2-hour headache response in 50-62% of patients 5
• Maximum daily dose is 200 mg in 24 hours; second dose may be given at least 2 hours after first dose 5
• Contraindicated in patients with coronary artery disease, uncontrolled hypertension, or cardiovascular risk factors due to vasoconstrictive properties 1, 6
• Adverse effects include transient flushing, tightness, or tingling in upper body in 25% of patients 6

Gepants (safer in cardiovascular disease):

• Ubrogepant or rimegepant (weak for recommendation) provide pain freedom at 2 hours in 20% of patients (NNT 13) 1, 6
• Adverse effects include nausea and dry mouth in 1-4% of patients 6
• Preferred over triptans in patients with cardiovascular risk factors 6

Adjunctive Treatment

Treat nausea proactively with antiemetics, not just in patients who are vomiting, as nausea itself is disabling. 1

Consider nonoral routes (nasal spray, subcutaneous) for patients with early nausea or vomiting. 1

Preventive Therapy Indications

Evaluate for preventive therapy if any of the following are present: 1

• Two or more attacks per month producing disability lasting 3+ days per month
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-line preventive agents: 1

• Propranolol 80-160 mg daily (long-acting formulation) 1
• Timolol 20-30 mg daily 1
• Amitriptyline 10-100 mg at night (most widely researched) 1, 4
• Topiramate 50-100 mg daily (contraindicated in pregnancy, nephrolithiasis, glaucoma) 1
• Divalproex sodium 500-1500 mg daily (absolutely contraindicated in women of childbearing potential) 1

Special Populations

Children and adolescents: Bed rest alone may suffice; if not, use ibuprofen for acute treatment and propranolol, amitriptyline, or topiramate for prevention. 1

Older adults: Consider higher risks of secondary headache, comorbidities, and adverse events; avoid triptans if cardiac risk factors exist. 1

Perimenstrual migraine: Consider daily long-acting NSAID (naproxen) or triptan (frovatriptan, naratriptan) for 5 days, beginning 2 days before expected menstruation. 1

Follow-Up and Monitoring

Evaluate treatment response within 2-3 months after initiation or change in treatment, then regularly at 6-12 month intervals. 1

Have patients maintain headache calendars documenting attack frequency, severity, duration, medication use, and disability to guide treatment adjustments. 1

Key outcome measures: Attack frequency (headache days per month), attack severity (pain intensity), and migraine-related disability. 1

Common Pitfalls to Avoid

Do not assume primary headache disorder without excluding secondary causes, especially in new-onset headache after age 50. 2

Do not start daily analgesics without establishing diagnosis, as this leads to medication-overuse headache. 2

Do not skip temporal arteritis workup in patients over 50 with new headache. 2

Do not use combined hormonal contraceptives in women with migraine with aura due to increased stroke risk. 1