What is the appropriate evaluation and management for a patient presenting with a headache?

Headache Evaluation and Management

Initial Assessment: Identify Red Flags First

Begin by systematically screening for life-threatening secondary causes using red flag features, as missing these can result in significant morbidity and mortality. 1, 2

Critical Red Flags Requiring Immediate Evaluation:

• Sudden onset "thunderclap" headache (consider subarachnoid hemorrhage) 1, 3
• New headache after age 50 (consider temporal arteritis, mass lesion) 1, 2
• Progressively worsening headache 1, 2
• Headache awakening patient from sleep (suggests increased intracranial pressure) 4, 1, 2
• Headache worsened by Valsalva maneuver 1, 2
• Focal neurologic signs or symptoms 4, 1
• Fever with headache (consider meningitis) 3
• Abrupt onset or marked change in headache pattern 4

If any red flags are present, obtain neuroimaging immediately—noncontrast CT for acute hemorrhage or mass effect, followed by lumbar puncture if CT is normal and subarachnoid hemorrhage is suspected. 4, 1, 3

Detailed History: Essential Elements

Obtain a comprehensive headache-specific history focusing on these key characteristics: 1, 2

Temporal Pattern:

• Onset characteristics (gradual vs. sudden) 1, 2
• Duration of episodes (4-72 hours suggests migraine) 4, 5
• Frequency (≥15 days/month suggests chronic migraine) 4, 1
• Time of day 4

Pain Characteristics:

• Location (unilateral vs. bilateral) 4
• Quality (pulsating, pressing, throbbing) 4
• Intensity (mild, moderate, severe) 4
• Aggravating factors (physical activity, Valsalva) 4, 1

Associated Symptoms:

• Nausea or vomiting 4
• Photophobia and phonophobia 4
• Aura symptoms (visual, sensory, speech disturbances lasting 5-60 minutes) 4, 1, 2
• Autonomic symptoms 4

Additional Critical Information:

• Current and past medication use (frequency of analgesic use is crucial to identify medication overuse headache) 4, 1
• Family history of migraine 4
• Trigger factors (alcohol, caffeine, foods, stress, sleep deprivation, hormonal changes) 4

A common pitfall is failing to document analgesic frequency—overuse of acute medications (≥10 days/month for triptans or combination analgesics, ≥15 days/month for simple analgesics) can cause medication overuse headache, which will not respond to treatment until the overused medication is withdrawn. 4, 1, 2

Diagnostic Classification

Migraine Without Aura:

Diagnose when patient has ≥5 attacks lasting 4-72 hours with at least two of the following: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine physical activity; AND at least one of: nausea/vomiting, photophobia and phonophobia. 4, 1, 5

Migraine With Aura:

Diagnose when patient has ≥2 attacks with reversible aura symptoms developing gradually over ≥5 minutes, each lasting 5-60 minutes, followed by headache within 60 minutes. 4, 1, 2

Chronic Migraine:

Diagnose when headache occurs ≥15 days per month for >3 months, with ≥8 days per month meeting migraine criteria. 4, 1

Tension-Type Headache:

Diagnose when headache has bilateral location, pressing/tightening quality, mild-to-moderate intensity, no aggravation with routine activity, and no nausea or vomiting (photophobia OR phonophobia may be present but not both). 1, 2

Medication Overuse Headache:

Suspect when headache occurs ≥15 days/month in a patient with pre-existing headache disorder who has been regularly overusing acute medications for >3 months (≥10 days/month for triptans, ergots, opioids, or combination analgesics; ≥15 days/month for simple analgesics). 4, 1, 2

Neuroimaging Indications

Obtain neuroimaging (MRI preferred over CT for higher resolution and no radiation) when: 1, 2

• Unexplained abnormal findings on neurological examination 4, 1, 2
• Any red flag features listed above 4, 1, 2
• Atypical headache patterns 4
• Rapidly increasing headache frequency 4
• History of uncoordination 4

Do NOT obtain neuroimaging for patients with migraine or tension-type headache who have normal neurological examinations and no red flags—the yield is extremely low (0.8% for brain tumors, 0.3% for migraine specifically) and does not change management. 4, 3, 6

Acute Treatment Strategy

First-Line: NSAIDs

For most patients with migraine, NSAIDs are first-line treatment, with strongest evidence for aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen-aspirin-caffeine. 4, 1 Acetaminophen alone is ineffective for migraine. 4

Second-Line: Triptans

Use migraine-specific agents (triptans or dihydroergotamine) when NSAIDs fail to provide adequate relief. 4, 1 Triptans with best evidence include oral sumatriptan (50-100 mg), rizatriptan, zolmitriptan, and naratriptan; subcutaneous sumatriptan provides fastest relief. 4, 7

Critical contraindications for triptans: 4, 7

• Uncontrolled hypertension
• Coronary artery disease or risk factors without cardiovascular evaluation
• Basilar or hemiplegic migraine
• History of stroke or TIA
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders

For triptan-naive patients with multiple cardiovascular risk factors (age >40, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing and consider administering first dose in supervised setting with ECG monitoring. 7

Route Selection:

Select nonoral route (nasal spray, subcutaneous injection) when nausea or vomiting are prominent early features of the attack. 4, 1 Treat nausea with antiemetics—nausea itself is disabling and should be treated even without vomiting. 4

Critical Limitation:

Limit acute medication use to no more than 2 days per week (≤10 days/month for triptans and combination analgesics, ≤15 days/month for simple analgesics) to prevent medication overuse headache. 4, 1, 2, 7

Preventive Therapy Indications

Initiate preventive therapy when: 4, 1, 2

• ≥2 migraine attacks per month producing disability for ≥3 days per month
• Using acute medications >2 days per week
• Failure of or contraindications to acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)
• Patient preference for prevention

First-Line Preventive Agents:

Evidence-based first-line options include: 4, 1, 2

• Propranolol 80-240 mg/day
• Timolol 20-30 mg/day
• Amitriptyline 30-150 mg/day
• Divalproex sodium 500-1500 mg/day
• Topiramate (for chronic migraine)
• CGRP monoclonal antibodies
• OnabotulinumtoxinA (for chronic migraine)

Start at low doses and titrate slowly over 2-3 months to assess efficacy, as clinical benefit may take this long to manifest. 4 After achieving stability (typically 6-12 months), consider tapering or discontinuing preventive therapy. 4

Medication Overuse Headache Management

When medication overuse headache is diagnosed, detoxification is necessary: 4, 1, 2, 7

• Withdraw the overused medication completely
• Warn patients that headaches will temporarily worsen during withdrawal
• Initiate appropriate preventive therapy simultaneously
• Avoid rescue medications containing butalbital, caffeine, or opioids as these have highest risk of rebound

Referral to Neurology

Refer to neurologist for: 2, 8

• Cluster headaches
• Uncertain diagnosis
• Poor response to preventive strategies
• Migraine with persistent aura
• Headache with motor weakness
• Atypical features despite normal initial workup

Patient Education and Monitoring

Implement headache diary tracking: 4, 1

• Frequency, severity, and duration of attacks
• Degree of disability
• Response to treatment
• Adverse medication effects
• Trigger identification (foods, alcohol, caffeine, stress, sleep patterns, hormonal factors)

This systematic approach prioritizes early identification of life-threatening secondary causes while providing evidence-based treatment for primary headache disorders, with particular attention to preventing medication overuse headache—a common and often overlooked cause of treatment failure.