What is the appropriate management for a patient with a headache?

Management of Headache

The appropriate management of a patient with headache begins with immediate assessment for life-threatening causes requiring urgent neuroimaging, followed by classification as primary versus secondary headache, and then tailored acute and preventive treatment based on headache type, frequency, and patient-specific factors. 1

Initial Assessment: Red Flags Requiring Immediate Action

First, identify red flags that mandate urgent neuroimaging (MRI or CT) before any treatment:

• Sudden onset "thunderclap" headache 1
• Fever accompanying headache 1
• Headache worsening with Valsalva maneuver or exercise 1
• Abrupt onset of severe headache 2
• Marked change in headache pattern 2
• Rapidly increasing frequency of headache 2
• Focal neurologic signs or symptoms 2
• Headache awakening patient from sleep 2
• New onset in older person (age ≥50 years) 2
• Persistent headache following head trauma 2
• History of uncoordination 2

If any red flags are present, obtain neuroimaging immediately before treating as primary headache. 1 In patients with normal neurologic examination and no red flags, neuroimaging is usually not warranted. 2, 1

History and Physical Examination: Key Elements

Obtain focused history addressing these specific elements:

• Frequency and timing of headaches 2
• Character of pain (throbbing, pressing, piercing, squeezing) 2
• Location (unilateral vs bilateral, frontal vs occipital) 2
• Duration of episodes 2
• Associated symptoms: nausea/vomiting, photophobia, phonophobia, autonomic features 2
• Aggravating factors (routine activity, position changes) 2
• Current medication use and response 2
• Triggers (stress, foods, sleep patterns, odors) 2
• In women: relationship to menstrual cycle 2, 1

Perform thorough neurologic examination to identify any abnormal findings. 2

Classification: Primary vs Secondary Headache

Primary Headache Diagnostic Criteria

Migraine requires at least 2 of the following: 2

• Unilateral location
• Throbbing character
• Moderate to severe intensity
• Worsening with routine activity

Plus at least 1 of: 2

• Nausea and/or vomiting
• Photophobia and phonophobia

Tension-type headache requires at least 2 of: 2

• Pressing, tightening, nonpulsatile character
• Mild to moderate intensity
• Bilateral location
• No aggravation with routine activity

Plus both of: 2

• No nausea or vomiting
• No photophobia and phonophobia (may have one or the other)

Cluster headache requires: 2

• Five attacks with frequency of 1-8 attacks per day
• Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes
• At least one ipsilateral autonomic feature (lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema)

Acute Treatment Strategy

For Mild to Moderate Migraine

First-line acute therapy includes: 1

• Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day)
• Combination therapy with aspirin + acetaminophen + caffeine for moderate-to-severe attacks

Add antiemetic 20-30 minutes before analgesic for synergistic effect: 1

• Metoclopramide 10 mg orally, OR
• Prochlorperazine 25 mg orally

Administer as early as possible during an attack to improve efficacy. 2

For Severe Migraine or Failed Oral Therapy

If oral therapy fails due to nausea/vomiting: 1

• Subcutaneous sumatriptan 6 mg is most rapid and effective (59% pain-free at 2 hours), OR
• Intranasal sumatriptan 5-20 mg

Important contraindications for triptans: 3

• Coronary artery disease
• Prinzmetal's angina
• Wolff-Parkinson-White syndrome
• Uncontrolled hypertension
• History of stroke or TIA
• Multiple cardiovascular risk factors without prior cardiovascular evaluation

For triptan-naive patients with multiple cardiovascular risk factors, perform cardiovascular evaluation first and consider administering first dose in medically supervised setting with ECG monitoring. 3

Critical Pitfall: Medication-Overuse Headache

Limit acute therapy to no more than 2 days per week to prevent medication-overuse headache (MOH). 1 Frequent use of ergotamine, opiates, analgesics (including NSAIDs), and triptans causes MOH, creating a vicious cycle of increasing headache frequency leading to daily headaches. 2, 1 Avoid opioids and butalbital-containing medications due to risks of dependency, rebound headaches, and loss of efficacy. 2

Preventive Therapy: Indications and Options

Preventive therapy is mandatory when: 1

• Continuous headache of prolonged duration, OR
• Frequent attacks requiring acute medication more than twice weekly, OR
• More than two headaches per week 2

First-Line Preventive Medications

Choose from: 1

• Propranolol 80-160 mg daily (long-acting formulation)
• Metoprolol 50-100 mg twice daily or 200 mg modified-release once daily
• Candesartan 16-32 mg daily

Beta-blocker contraindications: 1

• Asthma
• Cardiac failure
• Atrioventricular block
• Depression

Second-Line Preventive Medications

If first-line agents fail after adequate trial (2-3 months): 1

• Amitriptyline 10-100 mg at night
• Flunarizine 5-10 mg daily

Third-Line Preventive Medications

For refractory cases: 1

• OnabotulinumtoxinA 155-195 units every 12 weeks
• CGRP monoclonal antibodies (erenumab 70-140 mg monthly, fremanezumab 225 mg monthly)

Evaluate preventive therapy effectiveness at 2-3 months, as oral agents require this duration to demonstrate efficacy. 1

Special Populations: Women of Reproductive Age

In women of reproductive age, assess relationship to menstrual cycle (menstrual migraine). 1

Combined hormonal contraceptives are absolutely contraindicated if migraine with aura due to stroke risk. 1, 4

Pregnancy Considerations

For acute treatment in pregnancy: 4

• Paracetamol (acetaminophen) 1000 mg is first-line
• NSAIDs (ibuprofen) only during second trimester as second-line
• Metoclopramide for nausea is safe, particularly in second and third trimesters
• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail

Absolutely avoid in pregnancy: 4

• Ergotamine derivatives and dihydroergotamine (contraindicated throughout pregnancy)
• Topiramate, candesartan, sodium valproate (contraindicated due to fetal harm)
• Opioids and butalbital (risks of dependency, rebound headaches, potential fetal harm)

For preventive therapy in pregnancy (only if absolutely necessary): 4

• Propranolol has best safety data and is first choice
• Amitriptyline if propranolol contraindicated

Follow-Up and Monitoring

Re-evaluate within 2-3 months to assess: 1

• Attack frequency (headache days per month)
• Attack severity and pain intensity
• Migraine-related disability
• Adverse events from medications
• Adherence to treatment plan

Use headache calendars to track symptomatic days and acute medication use. 1

Referral Indications

Refer to neurologist for: 5

• Cluster headache
• Headache of uncertain diagnosis
• Poor response to preventive strategies after adequate trials
• Migraine with persistent aura
• Headache with associated motor weakness
• Unremitting headache in patient on long-term analgesics (consider medication-overuse headache)