What is the best course of action for a female patient experiencing recurring headaches in the occipital region?

Occipital Headaches: Diagnostic Approach and Management

Immediate Priority: Rule Out Spontaneous Intracranial Hypotension

For any patient with occipital (back of head) headaches, you must first determine if the headache has an orthostatic pattern—this is the critical distinguishing feature of spontaneous intracranial hypotension (SIH), a potentially serious but treatable condition. 1

Ask These Specific Timing Questions

• Is the headache absent or only mild upon waking in the morning? 1
• Does the headache develop within 2 hours of standing up or sitting upright? 1
• Does the headache improve by more than 50% within 2 hours of lying flat? 1
• Does this timing pattern occur consistently across episodes? 1

If the patient answers "yes" to these questions, order urgent MRI brain with IV contrast AND MRI complete spine simultaneously—do not delay. 1 The orthostatic pattern is pathognomonic for CSF leak. 1

Additional Red Flags for SIH

Actively assess for these accompanying symptoms that increase diagnostic certainty: 1

• Nausea and vomiting (present in 28% of cases) 1
• Neck pain or stiffness 1
• Tinnitus or hearing changes (11% of cases) 1
• Photophobia 1
• Visual disturbances (3% of cases) 1
• Vertigo (8% of cases) 1

Critical Pitfall to Avoid

Do not rely on CSF pressure measurement to rule out SIH—CSF pressure can be normal in patients with confirmed SIH, and absence of low pressure should not exclude this diagnosis. 1

If Orthostatic Pattern is Absent: Evaluate for Primary Headache Disorders

Determine Headache Frequency First

Ask: "Do you feel like you have a headache of some type on 15 or more days per month?" 2 This single question distinguishes chronic from episodic headache patterns and determines the entire treatment pathway. 2

For Chronic Pattern (≥15 headache days/month)

If the patient has headaches on 15 or more days per month for at least 3 months, with headaches lasting 4 or more hours, and at least 8 days per month have migraine features (throbbing pain, nausea, photophobia, or phonophobia), diagnose chronic migraine. 2

Management Algorithm for Chronic Migraine

1. Document current medication use carefully—ask specifically about over-the-counter analgesics, triptans, and any medications obtained from others. 3 Medication overuse headache perpetuates chronic migraine when simple analgesics are used ≥15 days/month or triptans ≥10 days/month. 4

2. Initiate prophylactic therapy immediately—every chronic migraine patient requires preventive treatment, not just acute management. 2

3. First-line prophylactic options (choose based on comorbidities and contraindications): 2

   • Topiramate 25-100mg daily (Level A evidence for chronic migraine) 2
   • Amitriptyline 25-150mg at bedtime 2
   • Propranolol 80-240mg daily (avoid if low blood pressure, asthma, or heart block) 2
   • Valproate 500-1500mg daily (contraindicated in pregnancy) 2

4. If 2-3 oral preventive medications fail or are contraindicated, consider onabotulinumtoxinA (Botox) 155-195 units to 31-39 sites every 12 weeks using the PREEMPT protocol. 4 This reduces headache days by approximately 2-3 days per month and is FDA-approved specifically for chronic migraine. 4

For Episodic Pattern (<15 headache days/month)

If headaches are unilateral, throbbing, moderate-to-severe intensity, worsened by activity, and accompanied by nausea or photophobia/phonophobia, diagnose migraine. 2

Acute Treatment Strategy

For mild-to-moderate migraine: 2

• NSAIDs: Ibuprofen 400-800mg, naproxen sodium 275-550mg, or aspirin 650-1000mg 2

For moderate-to-severe migraine or inadequate response to NSAIDs: 2

• Triptans are first-line: Sumatriptan 50-100mg, rizatriptan 10mg, or zolmitriptan 2.5-5mg 2
• Combination therapy (sumatriptan 85mg + naproxen 500mg) provides superior sustained pain-free rates (23-25%) compared to either agent alone (14-16%) 5

For nausea/vomiting: 2

• Add metoclopramide 10mg IV/PO or prochlorperazine 25mg PO/suppository 2
• Use non-oral routes (nasal spray, suppository, injection) if vomiting is prominent 2

Red Flags Requiring Urgent Neuroimaging

Order immediate head CT without contrast if any of these features are present: 2, 6

• Sudden onset of worst headache of life (thunderclap) 6
• Headache after head trauma 6
• Focal neurologic signs or symptoms 2, 6
• Papilledema 6
• Headache that awakens patient from sleep 2
• Rapidly increasing headache frequency 2
• New headache after age 50 7
• Immunocompromised state 6
• Personality changes 6
• Neck stiffness (consider meningitis or subarachnoid hemorrhage) 6

Special Consideration: Chiari I Malformation

In pediatric patients with isolated occipital headache worsened by Valsalva maneuver (coughing, straining, bending), order MRI brain with sagittal T2-weighted sequence of the craniocervical junction to evaluate for Chiari I malformation. 2 Occipital headache location is rare in children and warrants diagnostic caution. 2

Differential Diagnoses to Exclude

Before confirming primary headache disorder: 1

• Postural Orthostatic Tachycardia Syndrome (PoTS): Perform formal standing test with heart rate monitoring 1
• Orthostatic hypotension: Document blood pressure supine and standing 1
• Cervicogenic headache: Assess if headache is provoked by cervical movement rather than posture 1

Follow-Up Protocol

Schedule follow-up within 2-4 weeks to assess treatment response. 3 Use a headache diary to objectively document frequency, severity, and medication use. 3 Address comorbid conditions (depression, anxiety, chronic pain) that impair treatment effectiveness. 3