What is the recommended approach to managing headaches in patients with varying medical histories, including potential underlying causes such as trauma, stress, hypertension, or sinusitis?

Approach to Headache Management

For acute headache management, start with NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) or acetaminophen 1000 mg for mild-to-moderate pain, escalate to triptans plus NSAIDs for moderate-to-severe migraine, and initiate preventive therapy immediately if patients require acute treatment more than 2 days per week. 1

Initial Diagnostic Evaluation

Red Flag Assessment - Requires Urgent Neuroimaging or Emergency Evaluation

• Thunderclap onset (sudden, worst headache of life) suggests subarachnoid hemorrhage requiring immediate head CT without contrast 2
• Focal neurologic deficits (weakness, sensory changes, visual field cuts) indicate possible stroke or mass lesion 2
• Papilledema on fundoscopic exam suggests elevated intracranial pressure 2
• Fever with neck stiffness raises concern for meningitis requiring lumbar puncture 2
• New headache in patients ≥50 years increases risk of temporal arteritis or secondary causes 1, 2
• Immunocompromised state (HIV, cancer, immunosuppressants) elevates risk of opportunistic infections 3, 2
• Headache worsening with Valsalva, exercise, or postural changes suggests increased intracranial pressure 3, 2
• Personality changes or cognitive decline accompanying headache 2
• Post-traumatic headache within days-weeks of head injury 2

Primary Headache Classification

Once secondary causes are excluded, distinguish between primary headache types using International Headache Society criteria 1:

Migraine diagnostic features (requires ≥2 of the following) 1:

• Unilateral location
• Throbbing/pulsatile character
• Moderate-to-severe intensity
• Worsening with routine physical activity
• Plus nausea/vomiting OR photophobia and phonophobia

Tension-type headache features (requires ≥2 of the following) 1:

• Bilateral location
• Pressing/tightening (non-pulsatile) character
• Mild-to-moderate intensity
• No aggravation with routine activity
• No nausea/vomiting (may have anorexia)
• No photophobia AND phonophobia together (may have one)

Cluster headache features 1:

• Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes
• Frequency of 1-8 attacks daily
• Ipsilateral autonomic features: lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eyelid edema

Distinguish episodic from chronic migraine 1:

• Episodic migraine: <15 headache days per month
• Chronic migraine: ≥15 headache days per month with migraine features on ≥8 days

Medication Overuse Headache Screening

Critical to identify before escalating therapy 1, 4:

• Headache frequency ≥7 days per month
• Regular use of triptans ≥10 days per month
• Regular use of NSAIDs/acetaminophen ≥15 days per month
• History of anxiety, depression, or substance use
• Frequent use of anxiolytics or sedative-hypnotics

Acute Treatment Algorithm

Mild-to-Moderate Migraine (First-Line)

Start with NSAIDs or acetaminophen 1, 5:

• Ibuprofen 400-800 mg
• Naproxen sodium 500-825 mg
• Acetaminophen 1000 mg
• Aspirin-acetaminophen-caffeine combination (significant improvement with NNT of 9 for pain freedom at 2 hours) 4

Add antiemetic 20-30 minutes before analgesic for synergistic effect 5:

• Metoclopramide 10 mg (provides independent analgesic benefit beyond antiemetic properties) 5
• Prochlorperazine 25 mg (comparable efficacy to metoclopramide) 5

Moderate-to-Severe Migraine (Second-Line)

Triptans remain cornerstone therapy 1, 4:

• Sumatriptan 50-100 mg PLUS naproxen 500 mg (superior to either alone: 130 more patients per 1000 achieve sustained pain relief at 48 hours) 5
• Rizatriptan 10 mg (fastest oral triptan, peak concentration 60-90 minutes) 5
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg (more effective with fewer adverse reactions than sumatriptan) 5
• Naratriptan (longest half-life, decreases recurrence) 5

Try 2-3 different triptans before abandoning class - failure of one does not predict failure of others 5

Non-oral routes for significant nausea/vomiting 4, 5:

• Subcutaneous sumatriptan 6 mg (highest efficacy: 59% pain-free at 2 hours, onset within 15 minutes) 5
• Intranasal sumatriptan 5-20 mg 5

Triptan contraindications 5:

• Ischemic heart disease or previous myocardial infarction
• Uncontrolled hypertension
• Cerebrovascular disease
• Peripheral vascular disease

Alternative Acute Treatments When Triptans Contraindicated or Ineffective

CGRP antagonists (gepants) - preferred alternative 1, 4, 3:

• Ubrogepant 50-100 mg (20% pain-free at 2 hours, no vasoconstriction) 5, 3
• Rimegepant (particularly for patients with cardiovascular contraindications) 4, 3
• Adverse effects: nausea and dry mouth in 1-4% 3

Lasmiditan (5-HT1F agonist) 5, 3:

• 50-200 mg (safe in cardiovascular disease, no vasoconstriction) 5
• Critical warning: No driving or operating machinery for ≥8 hours due to CNS effects (dizziness, vertigo, somnolence) 5

Dihydroergotamine (DHE) 1, 5:

• Intranasal or IV formulation
• Good evidence for efficacy as monotherapy 1, 5

Emergency Department/Severe Refractory Migraine

IV combination therapy 5:

• Metoclopramide 10 mg IV (direct analgesic via dopamine receptor antagonism) 5
• PLUS Ketorolac 30 mg IV (rapid onset, 6-hour duration, minimal rebound risk) 5

Alternative IV options 5:

• Prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, fewer adverse events than chlorpromazine) 5
• DHE IV 5

Tension-Type Headache Acute Treatment

First-line 1, 4:

• Ibuprofen 400 mg 1, 4
• Acetaminophen 1000 mg 1, 4
• Combination analgesics containing caffeine 4

Critical Frequency Limitation - Preventing Medication Overuse Headache

Limit ALL acute medications to ≤2 days per week (≤10 days per month) 1, 4, 5:

• Triptans: medication overuse occurs at ≥10 days/month 4
• NSAIDs/acetaminophen: medication overuse occurs at ≥15 days/month 4
• Opioids, butalbital, ergotamine: highest risk for rebound headache 1

If exceeding this threshold, initiate preventive therapy immediately 4, 5

Preventive Therapy

Indications for Prevention 1, 4

• ≥2 migraine attacks per month producing disability lasting ≥3 days
• Use of acute medication >2 days per week
• Contraindication to or failure of acute treatments
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)
• Patient preference

First-Line Preventive Medications

For episodic migraine 1, 4:

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - most effective, assess efficacy after 3-6 months 1, 4
• Angiotensin receptor blockers (candesartan, telmisartan) 1, 4
• Lisinopril 1
• Topiramate (effective but weak recommendation due to adverse effects) 1, 4
• Valproate (avoid in women of childbearing potential - teratogenic) 1
• Memantine 1
• Atogepant (oral gepant for prevention) 1
• Magnesium 1

Beta-blockers 1, 4:

• Propranolol 80-240 mg/day (consistent evidence) 1, 4
• Timolol 20-30 mg/day 1
• Metoprolol, atenolol, nadolol (limited evidence) 1
• Avoid beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) - ineffective 1

For chronic migraine (≥15 headache days/month) 1, 4:

• OnabotulinumtoxinA (specifically for chronic migraine, NOT episodic) 1, 4
• CGRP monoclonal antibodies 4

For mixed migraine and tension-type headache 1, 4:

• Amitriptyline (more effective than propranolol for mixed presentations) 1, 4

For chronic tension-type headache prevention 1, 4:

• Amitriptyline 1, 4

Gabapentin is NOT recommended for episodic migraine prevention 1

Preventive Medication Principles 4

• Start at low doses and titrate slowly until benefits achieved without adverse effects 4
• Allow adequate trial periods: 2-3 months for oral agents, 3-6 months for CGRP antibodies, 6-9 months for onabotulinumtoxinA 4, 5
• Consider tapering after period of stability 4
• Failure of one preventive class does not predict failure of others 5

Non-Pharmacologic Approaches

Aerobic exercise or progressive strength training 1, 4:

• 2-3 times weekly for 30-60 minutes
• Effective for both migraine and tension-type headache prevention (weak recommendation) 1, 4

Physical therapy 1, 4:

• Delivered by physical therapist
• Reduces headache frequency and intensity in both migraine and tension-type headache 1, 4

Medications to Absolutely Avoid

Opioids (hydromorphone, meperidine, oxycodone) 1, 5:

• Questionable efficacy for headache
• Lead to dependency and medication overuse headache
• Loss of efficacy over time
• Reserve ONLY when all other options contraindicated, sedation acceptable, and abuse risk addressed 1, 5

Butalbital-containing compounds 1, 5:

• High risk for dependency and rebound headache
• Should be avoided entirely 5

Special Populations

Pregnancy

Acute treatment 6:

• First-line: Acetaminophen 1000 mg 6
• Second-line (second trimester only): Ibuprofen 6
• Metoclopramide for nausea 6
• Sumatriptan sporadically under specialist supervision if other treatments fail 6

Preventive therapy 6:

• Best avoided; consider only for frequent disabling attacks
• Propranolol (best safety data) 6
• Amitriptyline if propranolol contraindicated 6
• Contraindicated: Topiramate, candesartan, valproate, ergotamines 6

Cardiovascular Disease

Safe options 4, 3:

• Gepants (ubrogepant, rimegepant) - no vasoconstriction 4, 3
• Lasmiditan - no vasoconstriction 3
• NSAIDs (with caution for renal function and GI bleeding risk) 5

Avoid: Triptans, ergotamines 5, 3

Common Pitfalls to Avoid

1. Failing to screen for medication overuse headache before escalating therapy - this perpetuates the cycle 1, 4

2. Abandoning triptans after single failure - try 2-3 different triptans, as failure of one does not predict failure of others 5

3. Not initiating preventive therapy early enough - start when patients use acute medications >2 days/week 4, 5

4. Prescribing opioids or butalbital for routine headache management - creates dependency and worsens outcomes 1, 5

5. Inadequate trial duration for preventive medications - allow 2-3 months for oral agents before declaring failure 4

6. Missing secondary headache red flags - always evaluate for dangerous causes before treating as primary headache 3, 2

7. Using onabotulinumtoxinA for episodic migraine - only effective for chronic migraine (≥15 headache days/month) 1, 4