What is the approach to a patient presenting with headache, considering demographics, medical history, and severity of symptoms?

Approach to the Patient with Headache

Begin by immediately screening for red flags that require urgent evaluation or emergency referral, then systematically classify the headache as primary versus secondary, and finally determine the appropriate management pathway based on headache type and severity. 1, 2, 3

Step 1: Screen for Red Flags Requiring Urgent Action

Emergency department referral is mandatory for:

• Thunderclap headache (sudden onset, peaking within 1 second to 1 minute) to exclude subarachnoid hemorrhage 1, 4
• New headache after age 50 to exclude temporal arteritis, mass lesions, or other serious pathology 1, 2, 3
• Headache worsened by Valsalva maneuver (coughing, straining, bending) suggesting increased intracranial pressure 1, 2, 3
• Headache awakening patient from sleep which may indicate increased intracranial pressure or serious secondary cause 1, 2, 3
• Progressively worsening headache over days to weeks suggesting evolving pathology 1, 2, 3
• Fever or signs of infection requiring urgent evaluation for meningitis or encephalitis 1, 3
• Abnormal neurological examination findings mandating immediate imaging and specialist evaluation 1, 2, 3
• Recent head or neck injury 4
• Pregnancy with new headache 4
• Secondary risk factors such as cancer or HIV infection 4

Step 2: Obtain Focused History

Essential historical elements include:

• Age at onset and whether onset was at or around puberty (suggests migraine) 5
• Duration of individual headache episodes (4-72 hours suggests migraine; shorter duration may suggest cluster headache) 5, 3
• Frequency of episodes (≥15 days/month for >3 months suggests chronic migraine or chronic tension-type headache) 5, 2
• Pain characteristics: location (unilateral vs bilateral), quality (pulsating vs pressing/tightening), severity (moderate-severe vs mild-moderate), and aggravating factors 5, 2
• Accompanying symptoms: photophobia, phonophobia, nausea, vomiting, aura symptoms 5, 2
• Aura symptoms if present: visual, sensory, speech/language, motor, brainstem, or retinal symptoms that spread gradually over ≥5 minutes and last 5-60 minutes 5
• Family history of migraine (strengthens suspicion of migraine) 5
• Medication use: frequency and type of acute medications (≥15 days/month for non-opioid analgesics or ≥10 days/month for other acute medications suggests medication-overuse headache) 5, 2

Step 3: Classify Headache Type

Migraine Without Aura

Suspect when patient has:

• Recurrent moderate to severe headache, particularly if unilateral and/or pulsating 5
• At least two of: unilateral location, pulsating quality, moderate-severe intensity, aggravation by routine physical activity 5
• At least one of: nausea/vomiting OR both photophobia and phonophobia 5
• Headache attacks lasting 4-72 hours when untreated 5
• At least five attacks meeting these criteria 5

Migraine With Aura

Suspect when patient has:

• Symptoms above plus recurrent, short-lasting visual and/or hemisensory disturbances 5
• Fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal) 5
• Aura symptoms that spread gradually over ≥5 minutes, last 5-60 minutes, and are followed by headache within 60 minutes 5

Chronic Migraine

Suspect when patient has:

• ≥15 headache days per month for >3 months 5, 1
• On ≥8 days/month, headache meets criteria for migraine or is relieved by triptan/ergot derivative 5

Tension-Type Headache

Suspect when patient has:

• Bilateral, pressing/tightening (non-pulsatile) quality pain of mild-to-moderate intensity 2
• At least two of: bilateral location, pressing/tightening character, mild-moderate intensity, no aggravation with routine physical activity 2
• No nausea or vomiting (anorexia may be present) 2
• Either photophobia OR phonophobia may be present, but not both 2

Medication-Overuse Headache

Suspect when patient has:

• Headache on ≥15 days/month in someone with pre-existing headache disorder 5, 2
• Regular intake of non-opioid analgesics on ≥15 days/month for ≥3 months OR any other acute medication on ≥10 days/month for ≥3 months 5, 2

Step 4: Determine Need for Neuroimaging

MRI brain (preferred modality) is warranted when: 2, 3

• Any red flags are present 2, 3
• Unexplained abnormal findings on neurologic examination 2, 3
• Atypical features that don't fit established primary headache patterns 2, 3
• New onset in patients over 50 years 3

Neuroimaging is NOT warranted when: 3

• Normal neurologic examination with features consistent with primary headache disorders 3
• Long history of similar headaches without change in pattern 3

CT brain is preferred over MRI when: 4

• Trauma is present 4
• Abrupt onset of headache suggesting subarachnoid hemorrhage 4

Step 5: Determine Referral Pathway

Immediate Emergency Referral

Required for any red flags listed in Step 1 1, 2, 3

Non-Urgent Neurologist Referral

Required for: 1, 2, 3, 6

• Cluster headaches due to complex treatment requirements 1
• Headache with motor weakness (e.g., hemiplegic migraine) to exclude serious secondary causes 1, 6
• Migraine with persistent aura 1, 6
• Uncertain diagnosis after thorough primary care evaluation 1, 2, 6
• Poor response to preventive strategies after adequate trials of evidence-based therapies 1, 2, 6
• Chronic migraine (≥15 headache days per month for >3 months with migraine features on ≥8 days) for specialized treatments including onabotulinumtoxinA or CGRP monoclonal antibodies 1

Primary Care Management

Appropriate for: 1

• Typical migraine or tension-type headache with normal neurological examination and no red flags 1
• Episodic migraine responding to acute treatment with NSAIDs or triptans 1
• Long history of similar headaches without change in pattern and normal examination 1

Step 6: Initiate Management in Primary Care

For Episodic Migraine

Acute treatment options: 7

• First-line: NSAIDs, acetaminophen, or combination products with caffeine 7
• Triptans (5-HT1B/D agonists) eliminate pain in 20-30% of patients by 2 hours but should be avoided in patients with cardiovascular disease due to vasoconstrictive properties 7
• Gepants (CGRP receptor antagonists) such as rimegepant or ubrogepant eliminate headache in 20% of patients at 2 hours 7
• Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 7

Preventive therapy indications: 3

• Headaches occurring more than twice weekly 3
• Evidence-based options include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, valproate 3
• OnabotulinumtoxinA is FDA-approved for chronic migraine prophylaxis 3

For Tension-Type Headache

Acute treatment: 2

• First-line: naproxen sodium 500-825 mg at onset, or combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 2
• Limit acute treatment to no more than 2 days per week to prevent medication overuse headache 2

Preventive therapy indications: 2

• Headaches occurring ≥2 times per month causing significant disability 2
• First-line: propranolol 80-160 mg daily 2
• Alternatives: topiramate, antidepressants, CGRP monoclonal antibodies 2

Common Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 1
• Recognize medication overuse headache in patients taking analgesics >10 days per month; these patients may need specialist referral for detoxification 1, 2
• Avoid opioids for regular headache management due to risk of dependency and rebound headaches 3
• Maintain patients with stable, well-controlled headaches in primary care with regular monitoring, but react promptly to any change in headache pattern that may warrant re-referral 1