What are the guidelines for managing headaches in an adult patient with no significant medical history?

Headache Management in Adults Without Significant Medical History

Initial Red Flag Assessment

Begin by systematically screening for "red flags" that indicate potentially serious secondary headache disorders requiring urgent neuroimaging and further workup. 1

Critical warning signs include:

• Sudden onset "thunderclap" headache (consider subarachnoid hemorrhage) 2
• Headache worsened by Valsalva maneuver (suggests increased intracranial pressure) 3, 1
• Headache awakening patient from sleep 3, 1
• Progressive worsening pattern 3, 1
• New onset headache in patients over age 50 (consider temporal arteritis, mass lesion) 1, 2
• Fever or signs of infection 1
• Any abnormal neurological findings on examination 3

Neuroimaging Decision Algorithm

For patients with normal neurologic examination and typical features of primary headache (migraine or tension-type), neuroimaging is not warranted. 3, 1

The evidence is clear on this point: combining multiple studies totaling over 3,000 scans shows extremely low yield in patients with normal exams—brain tumors in only 0.8%, AVMs in 0.2%, aneurysms in 0.1% 2. This rate is no higher than incidental findings in completely asymptomatic individuals 3.

Neuroimaging should be obtained when: 3, 1

• Unexplained abnormal findings on neurologic examination
• Atypical features that don't fit established primary headache patterns
• Any red flags listed above are present

Diagnostic Classification

After excluding secondary causes, determine the primary headache type through targeted history:

Key diagnostic questions: 3

• Location: Unilateral (suggests migraine) vs bilateral (suggests tension-type)
• Character: Pulsating/throbbing (migraine) vs pressing/tightening (tension-type)
• Intensity: Moderate-severe with functional impairment (migraine) vs mild-moderate (tension-type)
• Duration: 4-72 hours untreated (migraine) vs 30 minutes to 7 days (tension-type)
• Associated symptoms: Nausea, photophobia, phonophobia (migraine features) 1
• Aggravation by routine physical activity (migraine characteristic)

Medication Overuse Headache Assessment

Critical pitfall: Always assess for medication overuse, which can transform episodic headaches into chronic daily headache. 3, 1, 4

Medication overuse headache thresholds: 5

• Triptans, ergots, combination analgesics: ≥10 days per month for ≥3 months
• Simple analgesics (acetaminophen, NSAIDs): ≥15 days per month for ≥3 months
• Opioids: Any regular use (avoid entirely for headache management) 1, 6

Include non-prescription analgesics and substances obtained from others in your medication history. 7

Acute Treatment Strategy

For Mild-to-Moderate Migraine:

Start with non-narcotic analgesics as early as possible during the attack. 3

• Combination therapy: Acetaminophen + aspirin + caffeine (acetaminophen alone is ineffective) 3
• NSAIDs: Ibuprofen 400-600 mg or naproxen 500 mg 6
• Ketorolac (parenteral NSAID option) 3

For Moderate-to-Severe Migraine:

Triptans are indicated for established migraine diagnosis with moderate-severe intensity. 4

• Use only after clear migraine diagnosis is established 4
• Contraindications: CAD, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, Wolff-Parkinson-White syndrome 4
• Perform cardiovascular evaluation in triptan-naive patients with multiple CV risk factors before prescribing 4
• Not indicated for prevention or cluster headache 4

Avoid opioids entirely—they risk dependency, medication overuse headache, and don't address underlying pathophysiology. 1, 6

Preventive Therapy Indications

Consider preventive therapy if headaches occur more than twice weekly, regardless of absolute number of headache days. 3, 1, 5

The threshold is not arbitrary—focus on functional impairment and inadequate response to acute treatment rather than waiting for a specific number of headache days 5.

First-Line Preventive Options:

For chronic migraine (≥15 headache days/month for >3 months with migraine features on ≥8 days): 1, 5

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Strongest evidence with favorable tolerability, reducing migraine days by 2-4.8 days/month 5
• Monthly subcutaneous injections with minimal systemic effects 5
• Monitor blood pressure with erenumab (postmarketing warnings for hypertension) 5

Alternative first-line options: 1, 5

• Topiramate: Only traditional preventive with RCT evidence specifically in chronic migraine; start 25 mg daily, titrate to 100-200 mg divided doses 5
  • Common side effects: cognitive slowing, paresthesias, weight loss, kidney stones 5
• OnabotulinumtoxinA: FDA-approved for chronic migraine prevention 1, 5

Other evidence-based preventive options: 1

• Gabapentin
• Tizanidine
• Amitriptyline
• Valproate
• Propranolol (for episodic migraine)

Titrate preventive medications slowly over 2-3 months to assess benefit while minimizing adverse effects—full benefit may take this long to manifest. 5

Comprehensive Management Plan

Maintain a headache diary to track frequency, severity, triggers, and treatment response. 1

Address modifiable factors: 1

• Identify and avoid personal triggers
• Establish regular sleep patterns
• Implement stress management techniques
• Screen for and treat comorbid depression, anxiety, substance abuse 7

Referral to neurology indicated for: 1

• Cluster headaches
• Uncertain diagnosis
• Poor response to preventive strategies
• Migraine with persistent aura
• Headache with motor weakness

Treatment Goals

Successful acute migraine management should: 3

• Treat attacks rapidly and consistently without recurrence
• Restore ability to function
• Minimize use of rescue medications
• Optimize self-care
• Cause minimal adverse effects

Continue appropriate acute therapy alongside preventive treatment—they are complementary, not mutually exclusive. 5