What is the appropriate evaluation and treatment for a patient with a headache?

Headache Evaluation and Management

Begin by ruling out life-threatening secondary causes using red flag criteria, then classify as primary headache disorder (most commonly migraine or tension-type), and treat with NSAIDs first-line for acute migraine, escalating to triptans if NSAIDs fail. 1

Initial Red Flag Assessment

Immediately evaluate for secondary causes if any of these features are present:

• Sudden onset "thunderclap" headache (requires emergent non-contrast CT to exclude subarachnoid hemorrhage) 1, 2
• New headache after age 50 (mandates neuroimaging and ESR/CRP to exclude temporal arteritis and prevent permanent vision loss) 1, 3
• Progressively worsening pattern over days to weeks 1
• Headache awakening patient from sleep 1
• Headache worsened by Valsalva maneuver 1
• Abnormal neurologic examination findings (any abnormality mandates immediate imaging) 1, 3
• Fever with meningeal signs 2
• Papilledema with focal neurologic deficits 2

For thunderclap headache: Order non-contrast CT immediately; if negative, perform lumbar puncture >6 hours from symptom onset to evaluate for xanthochromia (100% sensitive at 12 hours through 2 weeks post-hemorrhage) 3, 4

For new headache in older adults (≥50 years): Order ESR and CRP first to exclude temporal arteritis, then proceed to MRI brain as preferred imaging modality 3

Diagnostic Classification

If no red flags present, classify using International Headache Society criteria:

Migraine Without Aura

Requires at least 5 attacks with ALL of the following 1:

• Duration: 4-72 hours (untreated)
• At least TWO of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine physical activity
• At least ONE of: nausea/vomiting, photophobia AND phonophobia

Migraine With Aura

Requires at least 2 attacks with 1:

• Reversible aura symptoms developing gradually over ≥5 minutes
• Each aura symptom lasting 5-60 minutes
• Aura followed by headache within 60 minutes

Tension-Type Headache

Characterized by 1:

• Bilateral location
• Pressing/tightening (non-pulsating) quality
• Mild-to-moderate intensity
• No aggravation with routine activity
• No nausea or vomiting

Key clinical pearl: Pulsatile quality strongly suggests migraine over tension-type headache 5. Patients reporting "recurrent sinus headaches" or sensitivity to smells/sounds likely have migraine 2.

Neuroimaging Decisions

Order neuroimaging (MRI brain preferred over CT) for: 1, 3

• Any red flag symptoms listed above
• Unexplained abnormal neurologic examination
• New headache in patient >50 years old
• Progressively worsening headache pattern

Do NOT order neuroimaging for: 1

• Recurrent headaches with normal neurologic examination and no red flags
• Established primary headache disorder with typical pattern
• Tension-type headache meeting diagnostic criteria

The yield of neuroimaging in headache patients with normal examination is extremely low: brain tumors 0.8%, arteriovenous malformations 0.2%, aneurysms 0.1% 4. In migraine specifically, the yield is even lower: tumors 0.3%, AVMs 0.07%, aneurysms 0.07% 4.

Acute Migraine Treatment Algorithm

Step 1: First-Line Treatment

Start with NSAIDs for most patients with migraine 6:

• Aspirin, ibuprofen, naproxen sodium, or diclofenac potassium have strongest evidence 6
• Acetaminophen-aspirin-caffeine combination is effective 6
• Acetaminophen alone is ineffective and should not be used 6

Step 2: Second-Line Treatment

Escalate to triptans if NSAIDs provide inadequate relief after adequate trial (failure in ≥3 consecutive attacks) 6:

• All triptans have well-documented effectiveness 6
• Oral options: naratriptan, rizatriptan, zolmitriptan, sumatriptan 6
• Sumatriptan 50-100 mg achieves headache response (reduction to mild/no pain) in 50-62% at 2 hours and 68-79% at 4 hours, compared to 17-27% and 19-38% with placebo 7
• Take triptans early when headache is still mild for maximum effectiveness 6
• If one triptan fails, try another—different triptans may still provide relief 6

Triptan contraindications (from FDA label): 7

• Uncontrolled hypertension
• Coronary artery disease or risk factors without cardiovascular evaluation
• Basilar or hemiplegic migraine
• Wolff-Parkinson-White syndrome
• History of stroke or TIA

For cardiovascular evaluation in triptan-naive patients with multiple risk factors: Consider administering first dose in medically supervised setting with ECG monitoring 7

Step 3: Third-Line Treatment

If all triptans fail or are contraindicated, consider: 6

• Lasmiditan (ditan class)—efficacy comparable to triptans but causes temporary driving impairment 6
• Ubrogepant or rimegepant (gepants)—eliminate headache in 20% at 2 hours with adverse effects of nausea/dry mouth in 1-4% 8
• Dihydroergotamine intranasal (good evidence for efficacy and safety) 6

Special Considerations for Acute Treatment

For early nausea/vomiting: Use non-oral route of administration (subcutaneous sumatriptan, intranasal DHE) and treat nausea with antiemetic 6

For headache relapse: Can repeat triptan or combine with fast-acting NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium), but this increases medication overuse headache risk 6

Critical warning—Medication Overuse Headache: Limit acute treatment to no more than twice weekly 6. Using acute medications (triptans, NSAIDs, opioids, or combinations) ≥10 days per month leads to medication overuse headache, which presents as daily migraine-like headaches or marked increase in attack frequency 7. Detoxification requires withdrawal of overused drugs 1.

Preventive Therapy Indications

Initiate preventive therapy if: 6, 1

• ≥2 migraine attacks per month producing disability ≥3 days per month
• Using acute/rescue medication more than twice weekly
• Acute treatments fail or are contraindicated
• Uncommon migraine conditions present (prolonged aura, migrainous infarction, hemiplegic migraine)

Preventive medication options: 6, 8

• Topiramate: Only agent with proven efficacy in randomized controlled trials specifically for chronic migraine 6
• Propranolol, timolol (beta-blockers)
• Amitriptyline (tricyclic antidepressant)
• Valproate
• OnabotulinumtoxinA: FDA-approved specifically for chronic migraine prophylaxis (≥15 headache days per month), reduces headache days, episodes, and cumulative hours 6
• CGRP monoclonal antibodies: Reduce migraine by 1-3 days per month relative to placebo 8

Patient Education and Monitoring

Implement headache diary tracking: 6

• Severity, frequency, and duration of attacks
• Degree of disability from attacks
• Response to treatment and adverse effects
• Potential trigger factors (alcohol, caffeine, tyramine/nitrate-containing foods, stress, fatigue, perfumes, glare, flickering lights)

Establish realistic treatment expectations through shared decision-making: Discuss benefits and adverse effects of therapeutic options to guide selection of acute and preventive strategies 6

Referral Criteria

Refer to neurology or headache specialist for: 3

• Difficult-to-manage cases despite appropriate trials
• Atypical features despite negative workup
• Chronic daily headache requiring complex prophylactic therapy
• Need for onabotulinumtoxinA administration using specialized protocols

Common Pitfalls to Avoid

Do not assume primary headache in older adults (≥50 years): Up to 15% of patients ≥65 years presenting with new-onset headache have serious pathology (stroke, temporal arteritis, neoplasm, subdural hematoma) 4, 3

Do not skip temporal arteritis workup in older adults: ESR and CRP must be checked in all patients >50 with new headache, as ESR can be normal in 10-36% of temporal arteritis cases and biopsy can be false-negative in 5-44% 4, 3

Do not start daily analgesics without establishing diagnosis: This leads to medication overuse headache 3

Do not use triptans in older adults with cardiac risk factors without cardiovascular evaluation: Higher risk of adverse cardiovascular events with increasing age 3, 7