What is the best course of action for a patient with a 2-month history of headaches?

Evaluation and Management of 2-Month Headache

A patient with 2 months of continuous or near-daily headache requires urgent evaluation to exclude secondary causes—particularly giant cell arteritis if age ≥50 years, intracranial pathology, or spontaneous intracranial hypotension—before diagnosing and treating a primary headache disorder such as chronic migraine, new daily persistent headache, or chronic tension-type headache. 1, 2, 3

Initial Red Flag Assessment

First, determine if urgent neuroimaging or specialist evaluation is needed by screening for these red flags 2, 4, 5:

• Age ≥50 years with new-onset headache: Giant cell arteritis must be excluded, as headache is the most frequent presenting symptom and prompt corticosteroid treatment prevents permanent vision loss 6, 7, 3
• Thunderclap or sudden-onset headache: Suggests subarachnoid hemorrhage or other vascular catastrophe 2, 4
• Orthostatic features (worse when upright, better lying down): Evaluate for spontaneous intracranial hypotension with brain and spine MRI with contrast 4
• Progressive worsening pattern or headache awakening patient from sleep: Raises concern for mass lesion or increased intracranial pressure 2, 3
• Focal neurological deficits: Requires immediate neuroimaging 2, 5
• Worsening with Valsalva or lying down: Suggests increased intracranial pressure 2
• History of cancer or immunosuppression: Higher risk of metastatic disease or opportunistic infection 5, 3

Diagnostic Classification After Excluding Secondary Causes

If no red flags are present, classify the primary headache disorder based on frequency and phenotype 1, 4:

Chronic Migraine (Most Common)

• ≥15 headache days per month for >3 months, with migraine features on ≥8 days/month 1, 8
• Migraine features include: moderate-to-severe unilateral throbbing pain, nausea/vomiting, photophobia, phonophobia, worsening with physical activity 1, 5
• Critical pitfall: Only 20% of patients meeting chronic migraine criteria are correctly diagnosed because patients often underreport milder headache days 1
• Ask directly: "Do you feel like you have a headache of some type on 15 or more days per month?" 1

New Daily Persistent Headache

• Patient can pinpoint the exact day the daily headache began 4
• Headache becomes continuous and unremitting from onset 4
• Must exclude spontaneous intracranial hypotension with brain and spine MRI with contrast if any orthostatic features present 4

Chronic Tension-Type Headache

• Bilateral, pressing/tightening (non-pulsating) quality 2
• Mild-to-moderate intensity 2
• Not aggravated by routine physical activity 2
• No nausea/vomiting (though photophobia or phonophobia may occur) 2

Medication Overuse Headache Assessment

Before initiating preventive treatment, evaluate for medication overuse headache, which perpetuates chronic daily headache 8:

• Triptans, ergots, or combination analgesics: ≥10 days/month for ≥3 months 8
• Simple analgesics (acetaminophen, NSAIDs): ≥15 days/month for ≥3 months 8
• If medication overuse is present, withdrawal is necessary for preventive therapy to be effective 1

Preventive Treatment Strategy

For Chronic Migraine (First-Line)

CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) are first-line preventive treatment for chronic migraine, with strong evidence demonstrating 2-4.8 fewer migraine days per month and favorable tolerability 8:

• Administered as monthly subcutaneous injections 8
• Minimal systemic side effects compared to traditional preventives 8
• Monitor blood pressure with erenumab due to postmarketing reports of hypertension development or worsening 8
• Fremanezumab should be avoided in patients with history of stroke, subarachnoid hemorrhage, coronary heart disease, inflammatory bowel disease, COPD, or impaired wound healing 1

Alternative first-line option: Topiramate 50-100 mg daily 1, 8:

• The only traditional preventive with randomized controlled trial evidence specifically in chronic migraine 8
• Start at 25 mg daily, titrate slowly to minimize side effects 8
• Common adverse effects: cognitive slowing, paresthesias, weight loss, nephrolithiasis 1, 8
• Absolutely contraindicated in pregnancy and women of childbearing potential without reliable contraception 1

Third-line option: OnabotulinumtoxinA 1, 8:

• FDA-approved specifically for chronic migraine (≥15 headache days/month) 8
• 155-195 units injected into 31-39 sites every 12 weeks 1
• Consider if CGRP antibodies and topiramate fail or are contraindicated 1

For New Daily Persistent Headache

Treat based on predominant phenotype since no controlled trials exist specifically for NDPH 4:

• Migraine-like phenotype: Use CGRP monoclonal antibodies or topiramate as above 4
• Tension-type phenotype: Use amitriptyline as below 4

For Chronic Tension-Type Headache

Amitriptyline is the drug of first choice for chronic tension-type headache prophylaxis 2, 4:

• Start 10 mg at night, titrate to 10-100 mg based on response and tolerability 1
• Particularly beneficial if comorbid depression or sleep disturbances present 4
• Contraindicated in age <6 years, heart failure, concurrent monoamine oxidase inhibitors or SSRIs, glaucoma 1

Alternative: Beta-blockers (propranolol, metoprolol) if comorbid hypertension 2

Non-Pharmacologic Interventions

Recommend for all patients regardless of headache type 2, 4:

• Regular aerobic exercise or progressive strength training 2, 4
• Cognitive-behavioral therapy and biofeedback 4
• Physical therapy for tension-type headache 2

Monitoring and Follow-Up

Implement headache diary immediately to track frequency, severity, triggers, and acute medication use 1, 2, 4:

• Headache calendars require minimal time if completed only on symptomatic days 1
• Essential for monitoring medication overuse and treatment response 1

Evaluate treatment response at 2-3 months after initiating or changing preventive therapy 1, 8, 2:

• Full benefit may take 2-3 months to manifest; do not abandon therapy prematurely 8
• Key outcome measures: attack frequency, severity, and migraine-related disability 1
• Use validated tools: Migraine Treatment Optimization Questionnaire (mTOQ-4) for acute medication effectiveness, HURT questionnaire for preventive effectiveness 1

Continue appropriate acute therapy alongside preventive treatment 8:

• Acute migraine treatment: NSAIDs, triptans, gepants (rimegepant, ubrogepant), or lasmiditan 5
• Monitor for medication overuse headache development 2

Refer to headache specialist if 1, 2, 4:

• No improvement after 2-3 months of optimized preventive therapy 1
• Diagnostic uncertainty persists 2, 4
• Complex medication management needed 1

Special Population Considerations

Age ≥50 years 2, 3:

• Lower threshold for neuroimaging, as migraine typically remits with age while secondary headaches increase substantially 2
• Greater caution with medication side effects and drug interactions 2
• Higher suspicion for giant cell arteritis or intracranial mass lesion 3

Women of childbearing potential 1, 2:

• Absolutely avoid topiramate and valproate due to teratogenic effects 1, 2
• Consider pregnancy plans when selecting prophylactic medication 2