What is the appropriate initial management for a patient with a persistent headache lasting three weeks?

Initial Management of Persistent Headache Lasting Three Weeks

The appropriate initial management is to systematically screen for red flag features requiring urgent neuroimaging, then establish headache frequency and characteristics to differentiate between primary headache disorders (most likely tension-type or migraine) and initiate appropriate acute treatment while considering preventive therapy if attacks occur more than twice weekly. 1

Immediate Red Flag Assessment

Before assuming a primary headache disorder, you must actively screen for features suggesting life-threatening secondary causes:

• Rapidly increasing headache frequency over the 3-week period suggests evolving intracranial pathology and mandates neuroimaging 1
• Focal neurologic signs (weakness, sensory changes, visual field defects, ataxia) require immediate MRI with and without contrast 2
• Headache awakening the patient from sleep raises concern for mass lesion or increased intracranial pressure 1
• New headache in a patient over age 50 requires investigation for giant cell arteritis (check ESR/CRP) and structural causes 2
• Thunderclap onset (maximal intensity within seconds to minutes) demands urgent evaluation for subarachnoid hemorrhage 3, 4
• Headache provoked by Valsalva maneuver, cough, or exertion suggests posterior fossa lesion or Chiari malformation 4
• Systemic symptoms (fever, weight loss, immunosuppression, cancer history) indicate possible infection, malignancy, or inflammatory conditions 5, 4

If any red flags are present, obtain MRI brain with and without contrast before proceeding with primary headache treatment. 2 CT without contrast is acceptable in acute settings if hemorrhage is suspected, but MRI provides superior detection of masses, inflammation, and structural abnormalities. 2

Establish Headache Frequency and Pattern

Once secondary causes are excluded or deemed unlikely, directly ask the patient about headache frequency—patients often underestimate without a diary:

• Headache on ≥15 days per month for 3 months suggests chronic migraine or chronic tension-type headache 1
• Episodic attacks with headache-free intervals point toward migraine or cluster headache 3
• Daily or near-daily headache from onset raises concern for new daily persistent headache or secondary cause 3

The 3-week duration places this patient in the "recent onset with progressive installation" category, which requires heightened vigilance for secondary causes even without obvious red flags. 3

Differentiate Primary Headache Type

Migraine Features (Most Disabling Primary Headache)

• Moderate to severe intensity with throbbing/pulsating quality 5
• Unilateral location (though can be bilateral) 5
• Aggravated by routine physical activity 5
• Associated symptoms: nausea, vomiting, photophobia, phonophobia 1
• Duration: 4-72 hours if untreated 1
• History of at least 5 prior similar attacks supports migraine diagnosis 1

Tension-Type Headache Features (Most Common Primary Headache)

• Mild to moderate intensity with pressing/tightening quality 5
• Bilateral location 5
• Not aggravated by routine physical activity 5
• Minimal or no associated symptoms (mild photophobia or phonophobia, but not both) 5

Tension-type headache affects 38% of the population but is less disabling than migraine, which affects 12% but is the second leading cause of years lived with disability worldwide. 5

Initiate Acute Treatment Based on Headache Type

For Mild to Moderate Attacks (Likely Tension-Type or Mild Migraine)

• First-line: NSAIDs—ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 6, 5
• Alternative: Acetaminophen 1000 mg for patients intolerant to NSAIDs 6
• Enhanced option: Combination of acetaminophen 1000 mg + aspirin 500-1000 mg + caffeine 130 mg achieves pain reduction in 59.3% at 2 hours 6

For Moderate to Severe Attacks (Likely Migraine)

• First-line: Triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or naratriptan 2.5 mg) PLUS NSAID (naproxen 500 mg) 6
• This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 6
• Take medication early while pain is still mild for maximum effectiveness 6

For Attacks with Significant Nausea

• Add antiemetic: Metoclopramide 10 mg or prochlorperazine 25 mg taken 20-30 minutes before analgesic provides synergistic analgesia 6
• Consider non-oral routes: Intranasal sumatriptan 5-20 mg or subcutaneous sumatriptan 6 mg if vomiting is present 6

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit all acute medications to ≤2 days per week (≤10 days per month for triptans, ≤15 days per month for NSAIDs) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 6

This is a non-negotiable threshold—exceeding this frequency creates a self-perpetuating cycle where the medications themselves become the cause of chronic daily headache. 6

Initiate Preventive Therapy if Indicated

If the patient requires acute treatment more than twice weekly, preventive therapy should be initiated immediately rather than waiting for the pattern to become chronic. 1

First-Line Preventive Options

• Beta-blockers: Propranolol 80-240 mg/day or timolol 20-30 mg/day 6
• Topiramate: 50-100 mg/day (strongest evidence for chronic migraine among oral agents) 6, 2
• Candesartan: Alternative for patients with contraindications to beta-blockers 1
• Amitriptyline: 30-150 mg/day, particularly useful for mixed migraine and tension-type headache 6

Assess efficacy after 2-3 months at therapeutic dose before concluding treatment failure. 1

Essential Patient Counseling

• Maintain a headache diary tracking frequency, severity, duration, triggers, and medication response—this is essential for monitoring treatment response and preventing medication overuse 1
• Avoid opioids and butalbital-containing compounds as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 6
• Identify and address modifiable risk factors: obesity, excessive caffeine intake, sleep disorders, depression, anxiety, and stress 6

When to Refer to Neurology

• Red flags present despite normal initial evaluation 2
• Failure of two or more preventive medication classes at therapeutic doses 1
• Consideration of onabotulinumtoxinA (Botox) for chronic migraine after oral preventives fail 6
• Diagnostic uncertainty between primary and secondary headache disorders 7

Common Pitfalls to Avoid

• Assuming 3 weeks of headache is "chronic"—chronic headache requires >3 months duration, but this duration still warrants systematic evaluation 1
• Failing to screen for red flags before attributing symptoms to primary headache—recent onset headaches judged unusual by the patient must raise suspicion for secondary causes 3, 4
• Allowing patients to increase acute medication frequency in response to treatment failure—this creates medication-overuse headache rather than solving the problem 6
• Delaying preventive therapy while trialing multiple acute strategies—if attacks occur more than twice weekly, preventive therapy should begin immediately 1
• Using steroids as chronic prophylaxis—steroids have no role in long-term primary headache management and cause significant adverse effects 2