What is the appropriate approach to evaluate and manage headaches in a patient with an unknown medical history and demographic information?

Headache Evaluation: A Systematic Approach

Begin by immediately screening for red flags that indicate life-threatening secondary causes requiring urgent neuroimaging, then obtain a detailed temporal and symptom profile to classify the headache type, followed by targeted physical examination and selective diagnostic testing based on clinical findings. 1

Red Flag Assessment (Cannot-Miss Diagnoses)

Screen every patient for these critical warning signs that mandate immediate investigation:

• Sudden-onset "thunderclap" headache ("worst headache of life") suggests subarachnoid hemorrhage and requires emergent CT followed by lumbar puncture if CT is negative 1, 2
• New headache after age 50 raises concern for temporal arteritis, mass lesion, or stroke—up to 15% of patients over 65 with new-onset headache have serious pathology 1, 3
• Progressive worsening pattern over days to weeks indicates possible mass effect, subdural hematoma, or increased intracranial pressure 1, 4
• Headache awakening patient from sleep suggests increased intracranial pressure or secondary causes 1, 5
• Worsening with Valsalva maneuver (coughing, straining, bending) indicates possible posterior fossa lesion or Chiari malformation 1
• Focal neurological deficits on examination mandate neuroimaging to exclude stroke, tumor, or structural lesion 1, 6

Essential History Elements

Temporal Pattern Questions

• Onset and duration: Migraine lasts 4-72 hours; cluster headache lasts 15-180 minutes; tension-type is variable 1, 5, 6
• Frequency: Document whether episodic or ≥15 days/month (chronic daily headache threshold) 1, 5
• Time of day: Morning headaches suggest increased intracranial pressure; cluster headaches often occur at same time daily 5, 6

Pain Characteristics

• Location: Unilateral suggests migraine or cluster; bilateral suggests tension-type 1, 6
• Quality: Pulsating/throbbing indicates migraine; pressing/tightening suggests tension-type; severe stabbing with autonomic features indicates cluster 1, 6
• Severity: Rate on 0-10 scale—cluster headache is typically 8-10/10; migraine is moderate to severe 5, 6
• Aggravating factors: Routine physical activity worsens migraine but not tension-type; cluster patients pace restlessly rather than lie still 1, 5, 6

Associated Symptoms

• Nausea/vomiting, photophobia, phonophobia: Classic migraine features 1, 5
• Aura symptoms: Visual disturbances, numbness, tingling, or speech difficulties developing over ≥5 minutes and lasting 5-60 minutes indicate migraine with aura 1, 5
• Ipsilateral autonomic symptoms: Lacrimation, conjunctival injection, nasal congestion, ptosis, or miosis with unilateral headache are pathognomonic for cluster headache 6

Medication History (Critical for Medication Overuse Headache)

• Document all acute medications: Including over-the-counter analgesics, NSAIDs, triptans, opioids, and substances obtained from others 5, 7
• Frequency of use: ≥15 days/month for simple analgesics or ≥10 days/month for triptans/opioids indicates medication overuse headache 5, 7
• This is a common pitfall: Medication overuse can transform episodic headaches into chronic daily headaches through central sensitization 7

Physical and Neurological Examination

• Complete neurological examination is mandatory in all headache patients to detect focal deficits 1, 8
• Head and neck examination: Palpate temporal arteries for tenderness/decreased pulse (temporal arteritis in patients >50); assess for nuchal rigidity (meningitis); examine sinuses and teeth 7, 8
• Any abnormal neurological findings mandate neuroimaging regardless of headache characteristics 1, 6

Diagnostic Classification Based on History

Migraine Without Aura

Requires ≥5 attacks with ALL of the following 1:

• Duration 4-72 hours (untreated)
• At least TWO of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by routine activity
• At least ONE of: nausea/vomiting OR photophobia AND phonophobia

Migraine With Aura

Requires ≥2 attacks with 1:

• Reversible aura symptoms developing gradually over ≥5 minutes
• Each aura symptom lasting 5-60 minutes
• Aura followed by headache within 60 minutes

Tension-Type Headache

Characterized by 1:

• Bilateral location
• Pressing/tightening (non-pulsating) quality
• Mild to moderate intensity
• NOT aggravated by routine physical activity
• NO nausea or vomiting (photophobia OR phonophobia may be present, but not both)

Cluster Headache

Requires five attacks with 6:

• Severe unilateral orbital/supraorbital/temporal pain
• Duration 15-180 minutes
• Frequency 1-8 attacks daily during cluster periods
• At least ONE ipsilateral autonomic symptom (lacrimation, conjunctival injection, nasal congestion, ptosis, miosis)

Neuroimaging Indications

Order MRI brain (preferred over CT) when ANY of the following are present 1, 6:

• Unexplained abnormal neurological examination findings
• Any red flag features listed above
• Atypical headache pattern that doesn't fit primary headache criteria
• New neurological symptoms

Common pitfall: The yield of neuroimaging in patients with typical migraine or tension-type headache and normal examination is extremely low (0.8% for tumors, 0.2% for AVMs) 3. However, in the era of defensive medicine, document your clinical reasoning clearly when deferring imaging.

Diagnostic Tools

• ID-Migraine questionnaire: Three-question screening tool with 81% sensitivity and 75% specificity for migraine 5
• Headache diary: Have patients document frequency, duration, triggers, associated symptoms, and medication use for 4-8 weeks—this reduces recall bias and increases diagnostic accuracy 5
• SNNOOP10 screening tool: Systematic approach to identify secondary headache red flags 7

Management Approach Based on Diagnosis

Acute Treatment Goals

Prioritize 1:

• Rapid and consistent headache relief
• Restoration of function
• Minimize medication overuse
• Cost-effective management with minimal adverse effects

Migraine Acute Treatment

• Mild to moderate: NSAIDs, acetaminophen, or combination products with caffeine 1
• Moderate to severe: Triptans or CGRP antagonists (gepants)
• Monitor for medication overuse: Limit acute medications to <10 days/month for triptans, <15 days/month for simple analgesics 1, 7

Cluster Headache Acute Treatment

• First-line: Subcutaneous sumatriptan 6 mg (70% relief within 10 minutes) OR 100% oxygen at 12 L/min for 15 minutes (equal efficacy) 6
• Screen for cardiovascular risk before prescribing triptans: hypertension, hypercholesterolemia, smoking, diabetes, family history of CAD 6
• Alternative: Intranasal zolmitriptan 10 mg 6

Preventive Therapy Indications

Offer prophylaxis when 1:

• ≥2 headaches per week
• Chronic migraine (≥15 headache days/month)
• Significant disability despite acute treatment
• Contraindications to acute medications

Preventive Medication Options

• Migraine: Antihypertensives (propranolol, metoprolol), antiepileptics (topiramate, valproate), antidepressants (amitriptyline), CGRP monoclonal antibodies, or onabotulinumtoxinA for chronic migraine 1
• Cluster headache: Verapamil 360 mg/day (first-line) with ECG monitoring for PR prolongation; consider oral corticosteroids or occipital nerve block as bridge therapy 6

Medication Overuse Headache Management

If medication overuse is identified 1, 7:

• Opioids, barbiturates, benzodiazepines: Require slow taper, possibly inpatient detoxification to prevent withdrawal
• Other agents (NSAIDs, triptans, simple analgesics): Can withdraw more quickly, often as outpatient
• Implement preventive therapy simultaneously with detoxification
• Evidence is mixed on whether to use topiramate or other preventives during withdrawal, but most experts recommend starting prophylaxis 7

Follow-Up and Referral

• Regular scheduled follow-up is essential to monitor treatment response and adjust therapy 7
• Address comorbidities: Depression, anxiety, substance abuse, and chronic musculoskeletal pain impair treatment effectiveness 7
• Refer to headache specialist for difficult-to-manage cases, unclear diagnosis, or failure of multiple preventive trials 1