What is the initial management approach for an adult patient with no significant past medical history presenting with headache?

Initial Management of Headache in Adults with No Significant Past Medical History

Begin by systematically ruling out life-threatening secondary causes using red flag criteria, then proceed to differentiate primary headache disorders through structured history-taking and targeted physical examination. 1

Step 1: Screen for Red Flags Requiring Emergency Evaluation

Immediately assess for dangerous secondary headaches that mandate urgent imaging and specialist evaluation 1, 2:

• Thunderclap headache (sudden onset, peaking within 1 second to 1 minute) - suggests subarachnoid hemorrhage 3
• New-onset headache after age 50 - raises concern for temporal arteritis or mass lesions 1, 3
• Progressive worsening pattern over days to weeks - indicates evolving pathology 1, 2
• Headache worsened by Valsalva maneuver (coughing, straining, bending) - suggests increased intracranial pressure 1, 3
• Headache awakening patient from sleep - may indicate increased intracranial pressure 3, 2
• Focal neurological symptoms or signs on examination - mandates immediate imaging 4, 1
• Fever with neck stiffness - requires urgent evaluation for meningitis or encephalitis 1, 3
• Recent head or neck trauma with persistent headache 1

If any red flag is present, obtain neuroimaging immediately - MRI brain with and without contrast is preferred for subacute presentations, offering higher resolution without ionizing radiation 1. CT head without contrast is appropriate for acute presentations when subarachnoid hemorrhage is suspected 4.

Step 2: Obtain Focused Headache History

When red flags are absent, systematically gather the following information to differentiate primary headache types 4:

Essential temporal characteristics:

• Age at onset of headache 4
• Duration of individual episodes (4-72 hours suggests migraine; 15-180 minutes suggests cluster) 4, 1
• Frequency of episodes (≥15 days/month indicates chronic pattern) 4
• Time of day headaches occur 4

Pain characteristics:

• Location (unilateral vs. bilateral) 4
• Quality (pulsating vs. pressing/tightening) 4, 1
• Severity (mild-to-moderate vs. moderate-to-severe) 4, 1
• Aggravating factors (routine physical activity, Valsalva) 4

Associated symptoms:

• Nausea and/or vomiting 4
• Photophobia and phonophobia 4
• Autonomic features (lacrimation, nasal congestion, ptosis, miosis) 4

Aura symptoms if present:

• Visual, sensory, speech/language, motor, or brainstem symptoms 4
• Duration and progression pattern of aura 4

Medication history:

• Current acute and preventive medication use 4
• Frequency of analgesic use (≥10 days/month for any acute medication or ≥15 days/month for non-opioid analgesics suggests medication-overuse headache) 4, 5

Family history - migraine has strong genetic component 4

Step 3: Perform Targeted Physical and Neurological Examination

Conduct thorough neurological assessment focused on 4:

• Complete cranial nerve examination 4
• Motor strength and coordination testing 4
• Sensory examination 4
• Deep tendon reflexes 4
• Gait assessment 4
• Head and neck examination for tenderness, temporal artery abnormalities 2

Normal neurological examination with features consistent with primary headache disorder does NOT require neuroimaging 2.

Step 4: Differentiate Primary Headache Disorders

Migraine Without Aura

Suspect when headache is unilateral, pulsating, moderate-to-severe, and accompanied by nausea/vomiting OR photophobia plus phonophobia, with duration of 4-72 hours when untreated 1. Requires at least 5 lifetime attacks meeting these criteria 4, 1.

Diagnostic criteria require at least two of four pain characteristics (unilateral, pulsating, moderate-to-severe intensity, aggravation by routine activity) AND at least one associated symptom (nausea/vomiting OR photophobia and phonophobia) 4.

Migraine With Aura

Requires ≥2 attacks with fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal) 4, 1. At least one aura symptom must spread gradually over ≥5 minutes, each symptom lasts 5-60 minutes, and aura is accompanied by or followed by headache within 60 minutes 4.

Tension-Type Headache

Diagnose when headache is bilateral, pressing or tightening quality, mild-to-moderate intensity, and NOT aggravated by routine physical activity 1. No nausea/vomiting (though anorexia may occur) and no photophobia AND phonophobia together (may have one or the other) 4, 1.

Cluster Headache

Strictly unilateral orbital/periorbital/temporal pain, severe or very severe intensity, short duration (15-180 minutes), and frequency of 1-8 attacks daily during cluster periods 4, 1. Must have at least one ipsilateral autonomic feature (lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema) 4.

Step 5: Identify Medication-Overuse Headache

Suspect in any patient with ≥15 headache days per month who regularly overuses acute medications for >3 months 4:

• Non-opioid analgesics on ≥15 days/month for ≥3 months 4
• Triptans, ergots, opioids, or combination analgesics on ≥10 days/month for ≥3 months 4, 5

This diagnosis requires a pre-existing primary headache disorder 4. Patients overusing opioids, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal 5.

Step 6: Implement Diagnostic Tools

Initiate a headache diary to track frequency, severity, triggers, duration, associated symptoms, and treatment response over time 4, 2. This is essential for accurate diagnosis, reduces recall bias, and allows systematic application of diagnostic criteria over multiple attacks 1.

Consider validated screening questionnaires such as ID-Migraine or Migraine Screen Questionnaire to confirm migraine diagnosis 1.

Step 7: Determine Need for Neuroimaging

Neuroimaging is NOT warranted when 2:

• Normal neurological examination 2
• Features consistent with primary headache disorders 2
• Long history of similar headaches without change in pattern 2

Neuroimaging IS warranted when 2:

• Unexplained abnormal findings on neurological examination 2
• New onset in patients over 50 years 2
• Atypical features that don't fit established primary headache patterns 2
• Rapidly increasing frequency of headache 4
• History of uncoordination 4

Step 8: Identify Patients Requiring Specialist Referral

Refer to neurologist for 3, 6:

• Cluster headaches (complex treatment requirements) 3
• Headache with motor weakness (e.g., hemiplegic migraine) 3
• Migraine with persistent aura 3, 6
• Uncertain diagnosis after thorough primary care evaluation 3, 6
• Poor response to preventive strategies after adequate trials 3, 6
• Chronic migraine (≥15 headache days/month for >3 months with migraine features on ≥8 days) 3

Typical migraine or tension-type headache with normal neurological examination and no red flags can be managed in primary care 3.

Common Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 3
• Recognize medication overuse headache early - patients taking analgesics >10 days per month may need specialist referral for detoxification 3, 5
• Do not order routine neuroimaging for typical primary headaches with normal examination - this increases costs without improving outcomes 2
• Avoid opioids for regular headache management due to risk of dependency and rebound headaches 2