What treatment and further workup are recommended for a patient with daily headaches and a normal Magnetic Resonance Imaging (MRI) brain result?

Daily Headaches with Normal MRI: Treatment and Further Workup

For a patient with daily headaches and normal MRI, initiate preventive therapy immediately with topiramate (starting 25-50 mg nightly, titrating to 100 mg daily) or propranolol (80-160 mg daily), while simultaneously addressing medication overuse if present and implementing lifestyle modifications. 1, 2

Diagnostic Clarification

With a normal MRI and neurologic examination, you have effectively ruled out secondary causes requiring urgent intervention 1. The key now is determining whether this represents:

• Chronic migraine (≥15 headache days/month with ≥8 days having migraine features) 1
• Medication-overuse headache (frequent use of acute medications causing rebound) 1
• Chronic tension-type headache (less likely given daily frequency) 1

Ask the patient directly: "Do you feel like you have a headache of some type on 15 or more days per month?" 1. This simple question is more reliable than asking patients to recall exact numbers.

Essential History Elements to Obtain Now

Document the following specific details:

• Headache character: Unilateral, pulsating quality, moderate-to-severe intensity, and aggravation by activity suggest migraine 3
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia point toward migraine 4, 3
• Medication use patterns: Document frequency of analgesic, NSAID, or triptan use—more than 10 days per month indicates medication overuse 1
• Triggers: Caffeine intake, meal patterns, sleep hygiene, stress levels 1
• Impact on function: Inability to work, attend social functions, perform routine activities 1

Have the patient maintain a headache diary tracking frequency, duration, intensity, associated symptoms, and all medication use 4, 5.

Immediate Management Strategy

Step 1: Address Medication Overuse First (If Present)

If the patient uses acute medications (NSAIDs, triptans, analgesics) >10 days per month, medication-overuse headache is likely perpetuating the daily pattern 1:

• Non-opioids and triptans: Stop abruptly or wean within one month 1
• Opioids (if present): Gradually taper over at least one month 1
• Critical point: Preventive therapy will not work effectively until medication overuse is eliminated 1

Step 2: Initiate Preventive Therapy

Do not wait—preventive therapy should be started immediately for patients with daily or near-daily headaches 1, 2.

First-Line Preventive Options:

Topiramate is the only agent with proven efficacy specifically in chronic migraine from randomized controlled trials 1, 6:

• Start 25-50 mg nightly 7
• Increase by 25 mg weekly to target dose of 100 mg daily 2, 7
• 25% of patients respond to 50 mg daily, but 50% require 100 mg daily 7
• Warn about paresthesias, cognitive effects, weight loss, kidney stones 1

Propranolol (if no contraindications like asthma, heart block) 2, 6:

• 80-160 mg daily in divided doses 4, 2
• Alternative beta-blockers: metoprolol or timolol 2, 6

Amitriptyline (particularly if comorbid depression or insomnia) 8, 6:

• Start 10-25 mg nightly, titrate to 50-150 mg 8
• Warn about dry mouth, constipation, weight gain 8

Second-Line Options (if first-line fails or contraindicated):

• Divalproex sodium 500-1000 mg daily (avoid in women of childbearing potential) 2, 8
• Gabapentin 1200-2400 mg daily in divided doses 2, 8
• Venlafaxine 150 mg daily 2

Step 3: Optimize Acute Treatment

For breakthrough headaches, limit acute medication to ≤2 days per week or maximum 10 days per month to prevent medication overuse 1:

For migraine-type exacerbations:

• NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) plus antiemetic 1, 4
• Triptans as second-line if NSAIDs fail after three consecutive attacks 4

Avoid opioids and butalbital-containing compounds as they promote medication overuse and dependence 1.

Step 4: Lifestyle Modifications (Non-Negotiable)

Implement these simultaneously with pharmacotherapy 1:

• Limit caffeine intake to consistent daily amounts 1
• Regular meals and adequate hydration 1
• Sleep hygiene: consistent sleep/wake times 1
• Regular aerobic exercise program 1
• Stress management: cognitive-behavioral therapy, mindfulness, yoga 1

Further Workup Considerations

When Additional Testing IS Needed:

Despite normal MRI, consider these specific scenarios:

ESR and CRP if patient is >50 years old with new-onset headache pattern to exclude giant cell arteritis 3, 5

MRI with MR angiography if pulsatile quality suggests vascular anomaly (dural fistula, venous anomalies) 3

Lumbar puncture only if suspicion for idiopathic intracranial hypertension (particularly in women of childbearing age with obesity, papilledema, or pulsatile tinnitus) 1—but note that LP is not recommended for routine headache treatment 1

When Additional Testing is NOT Needed:

• Repeat MRI: Not indicated with normal neurologic exam and typical headache pattern 1
• CT scan: Adds nothing after normal MRI 1
• EEG, blood work, or other tests: Not routinely helpful 5

Follow-Up Timeline

Re-evaluate in 2-3 months to assess 4:

• Reduction in headache frequency (goal: ≥50% reduction) 8
• Response to acute treatment strategies 4
• Medication overuse patterns 4
• Tolerability of preventive medication 8
• Need for dose adjustment or alternative agent 8

Give each preventive medication an adequate trial: 6-8 weeks at target dose before declaring failure 8, 7.

Referral to Neurology/Headache Specialist

Refer if 4, 5:

• Poor response to two first-line preventive medications at adequate doses 4
• Attacks become more frequent or severe despite treatment 4
• Atypical features despite negative workup 4, 5
• Diagnostic uncertainty remains 4
• Patient requires advanced therapies (e.g., onabotulinumtoxinA, CGRP antagonists) 1

Critical Pitfalls to Avoid

• Do not assume this is "just tension headache" and withhold preventive therapy—daily headaches warrant prevention regardless of subtype 1, 2
• Do not start daily analgesics without establishing diagnosis—this creates medication overuse headache 5
• Do not continue ineffective preventive therapy indefinitely—if no response after adequate trial, switch agents 8
• Do not overlook medication overuse—it prevents all other treatments from working 1
• Do not skip contraception counseling when prescribing topiramate or valproate in women of childbearing age 8, 6