What is an AMC exam‑focused, step‑by‑step approach to assess and manage headaches, including red‑flag evaluation, history, physical examination, primary and secondary headache treatment, and preventive measures?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 7, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

AMC Exam-Focused Approach to Headaches

Step 1: Red Flag Assessment (Rule Out Secondary Headaches First)

Immediately identify red flags that mandate urgent neuroimaging or emergency referral before considering primary headache diagnoses. 1, 2

Critical Red Flags Requiring Immediate Action:

  • Thunderclap headache ("worst headache of life") → suspect subarachnoid hemorrhage; obtain non-contrast CT head if presenting <6 hours from onset (sensitivity 95% on day 0) 2, 3
  • New-onset headache after age 50 → consider giant cell arteritis (check ESR/CRP, refer to rheumatology) or space-occupying lesion 2, 4
  • Focal neurological signs or symptoms → obtain MRI brain with and without contrast 2, 5
  • Altered consciousness, memory, or personality changes → emergency admission 2, 6
  • Headache with fever and neck stiffness → suspect meningitis; emergency evaluation 2, 3
  • Progressive worsening over days to weeks → suspect space-occupying lesion or increased intracranial pressure 2, 4
  • Headache awakening patient from sleep → warrants neuroimaging 7, 2
  • Headache worsened by Valsalva, cough, or exertion → suspect increased intracranial pressure 2, 5
  • Recent head or neck trauma → obtain CT head acutely 2, 5
  • Papilledema on examination → emergency referral 3, 6

Imaging Decision Algorithm:

  • Non-contrast CT head: Acute trauma, abrupt-onset severe headache, or presenting <6 hours from thunderclap onset 2, 3
  • MRI brain with and without contrast: Subacute presentations, suspected tumor/inflammatory process, or any other red flag with normal CT 2, 5
  • Lumbar puncture: If CT normal but subarachnoid hemorrhage still suspected, or if meningitis/encephalitis considered 8, 5

Common pitfall: Do NOT order routine neuroimaging in patients with normal neurologic examination and typical primary headache features—yield is only 0.2%, no higher than asymptomatic volunteers 2

Step 2: Detailed Headache History (Differentiate Primary Headache Types)

Obtain a systematic history using these specific elements to classify the primary headache disorder. 7, 2

Essential History Components:

  • Frequency and timing: How often? What time of day? Relation to menstrual cycle in women? 7, 2
  • Duration of episodes: Migraine 4-72 hours; cluster 15-180 minutes; tension-type variable 2, 4
  • Pain location: Unilateral (migraine, cluster) vs bilateral (tension-type) 2, 4
  • Pain quality: Pulsating (migraine) vs pressing/tightening (tension-type) vs severe unilateral (cluster) 2, 4
  • Pain severity: Moderate-to-severe (migraine, cluster) vs mild-to-moderate (tension-type) 2, 4
  • Aggravating factors: Routine physical activity worsens migraine but NOT tension-type 2, 4
  • Associated symptoms: Nausea/vomiting, photophobia AND phonophobia (migraine); ipsilateral lacrimation, conjunctival injection, nasal congestion, ptosis, miosis (cluster); neither (tension-type) 2, 4
  • Aura symptoms: Visual/hemisensory disturbances lasting <60 minutes, gradual spread over ≥5 minutes (migraine with aura) 2
  • Medication use: Document all acute and preventive medications, frequency of use (screen for medication-overuse headache) 7, 2
  • Triggers: Stress, weather, odors, foods, missed meals, sleep patterns 7, 2
  • Family history: Strong genetic component in migraine 2

Validated Screening Tools:

  • ID-Migraine questionnaire (3-item): Sensitivity 81%, specificity 75%, positive predictive value 93% 2
  • Migraine Screen Questionnaire (5-item): Sensitivity 93%, specificity 81%, positive predictive value 83% 2
  • Headache diary: Reduces recall bias, increases diagnostic accuracy; document frequency, duration, character, triggers, accompanying symptoms, medication use 2

Step 3: Physical and Neurologic Examination

Perform a targeted examination focusing on neurologic signs and specific findings that distinguish primary from secondary headaches. 7, 2

Key Examination Elements:

  • Vital signs: Fever suggests infection or giant cell arteritis 2, 3
  • Fundoscopy: Check for papilledema (increased intracranial pressure) 3, 6
  • Neck examination: Assess for stiffness, limited neck flexion (meningitis), scalp tenderness (giant cell arteritis) 2, 3
  • Cranial nerve examination: Focal deficits suggest secondary cause 2, 5
  • Motor and sensory examination: Focal weakness or sensory loss warrants neuroimaging 2, 3
  • Coordination and gait: Uncoordination increases odds of positive neuroimaging 7, 5
  • Mental status: Altered consciousness, memory, or personality changes require emergency evaluation 2, 6

Critical point: A completely normal neurologic examination in a patient with typical primary headache features has a very low yield (0.2%) for serious intracranial pathology 2

Step 4: Diagnostic Criteria for Primary Headaches

Migraine Without Aura (Most Common in Primary Care):

Requires at least 5 lifetime attacks meeting ALL of the following: 1, 2

  • Duration 4-72 hours (untreated or unsuccessfully treated)
  • At least 2 of these pain characteristics: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine physical activity
  • At least 1 of these: nausea/vomiting, OR photophobia AND phonophobia

Migraine With Aura:

Requires recurrent attacks with: 2

  • Visual, sensory, speech/language, motor, brainstem, or retinal symptoms
  • At least 3 characteristics: gradual spread over ≥5 minutes, two or more symptoms in succession, at least one unilateral symptom, at least one positive symptom, aura accompanied by or followed by headache within 60 minutes

Tension-Type Headache:

Requires at least 2 of these pain characteristics: 2, 4

  • Bilateral location
  • Pressing or tightening (non-pulsatile) quality
  • Mild-to-moderate intensity
  • No aggravation with routine physical activity

AND both of these: 4

  • No nausea or vomiting (anorexia may be present)
  • No photophobia AND phonophobia (may have one or the other, but not both)

Cluster Headache:

Characterized by: 2

  • Strictly unilateral severe orbital or temporal pain
  • Duration 15-180 minutes
  • Ipsilateral autonomic symptoms: lacrimation, conjunctival injection, nasal congestion, ptosis, miosis
  • Restlessness or agitation during attacks

Chronic Migraine:

Defined as: 2

  • ≥15 headache days/month for >3 months
  • With ≥8 days meeting migraine criteria

Medication-Overuse Headache:

Suspect when: 2, 4

  • ≥15 headache days/month
  • Regular overuse of non-opioid analgesics ≥15 days/month for ≥3 months, OR
  • Any other acute medication ≥10 days/month for ≥3 months

Step 5: Acute Treatment Strategies

For Migraine:

First-line (mild-to-moderate attacks): 1, 2

  • NSAIDs: Acetylsalicylic acid, ibuprofen, or diclofenac potassium (strongest evidence for efficacy)
  • Combination: Aspirin + acetaminophen + caffeine for moderate-to-severe attacks

Second-line (moderate-to-severe attacks or inadequate response to NSAIDs): 1, 2

  • Triptans: Most effective when taken early in the attack
  • Antiemetics: For nausea/vomiting

Critical pitfall: Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache 4

For Tension-Type Headache:

First-line: 4

  • Naproxen sodium 500-825 mg at onset
  • Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks

Limit use to ≤2 days per week to prevent medication-overuse headache 4

For Cluster Headache:

First-line: 2

  • High-flow oxygen: 100% at 12-15 L/min
  • Subcutaneous or intranasal triptans: Alternative acute treatment

Step 6: Preventive Therapy Indications

Consider preventive medications when: 1, 4

  • Patients experience >2 headaches per week
  • Frequent episodic migraine causing significant disability
  • Inadequate response to acute treatment
  • Headaches occur ≥2 times per month causing significant disability
  • Continuous headache of prolonged duration

First-Line Preventive Options:

For Migraine: 1

  • CGRP monoclonal antibodies: Strongest evidence and favorable tolerability; reduce migraine days by 2-4.8 days per month; administered as monthly subcutaneous injections

For Tension-Type or Migraine: 4

  • Propranolol 80-160 mg daily
  • Alternative options: Topiramate, antidepressants

Step 7: Referral and Follow-Up Criteria

Emergency Admission (Immediate): 2

  • Patient unable to self-care without help
  • Any red flag present

Urgent Neurology Referral (Within 48 Hours): 2

  • Suspected spontaneous intracranial hypotension (orthostatic headache)
  • Patient unable to self-care but has help

Routine Neurology Referral (2-4 Weeks): 2, 4

  • Suspected primary headache disorder with diagnosis uncertain
  • First-line treatments fail after adequate trials
  • Motor weakness or persistent aura develops
  • Chronic daily headache pattern emerges

Urgent Specialist Referral (Within 1 Month): 2

  • Diagnosis in doubt after thorough evaluation
  • Rapid clinical deterioration
  • Serious complications

Rheumatology Referral: 2

  • Suspected giant cell arteritis (new-onset headache in patient >50 years with scalp tenderness, jaw claudication, elevated ESR/CRP)

Note: ESR can be normal in 10-36% of giant cell arteritis cases 2

Critical Pitfalls to Avoid for AMC Exam

  1. Do NOT order routine neuroimaging in patients with normal neurologic examination and typical primary headache features—this is a common exam trap 1, 2

  2. Do NOT miss medication-overuse headache—screen for overuse of triptans, ergotamine, opiates, and analgesics causing rebound headaches 1, 2

  3. Do NOT assume a preexisting headache excludes secondary causes—pattern change in a known headache disorder warrants re-evaluation 9

  4. Do NOT forget to check ESR/CRP in new-onset headache after age 50—giant cell arteritis can cause permanent vision loss if missed 2

  5. Do NOT perform lumbar puncture before neuroimaging—risk of herniation if mass effect present 8, 5

  6. Do NOT use CT alone to rule out subarachnoid hemorrhage after 6 hours—sensitivity drops to 74% on day 3; lumbar puncture required if CT normal 2

  7. Do NOT diagnose "sinus headache" without confirming sinusitis—most are actually migraines 6

References

1
Guideline

Management of New Headaches Without Red Flags

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Approach to Assessment of Headache

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Approach to acute headache in adults.

American family physician, 2013

4
Guideline

Tension-Type Headache Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Acute Headache in Adults: A Diagnostic Approach.

American family physician, 2022

7
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

8
Research

Evaluation of acute headaches in adults.

American family physician, 2001

Related Questions

How can the Socrates method be used to rule out migraine?
What are the red flags for headache diagnosis?
What are the red flags for headache that require immediate medical evaluation?
What could be causing left-sided pain while walking in an adult with a history of recurring left-sided headaches originating from the nasal region?
What could be causing my severe, sharp, stabbing headaches that started 2-3 days ago, are moderate to severe in intensity, last a few seconds, occur every 15-20 minutes, and are unresponsive to Tylenol (acetaminophen) Extra Strength, despite being able to sleep with the pain and having no eye pain, vomiting, or weakness?
What are the recommended pharmacologic options for treating functional or chronic constipation in adults, including management of opioid‑induced constipation and considerations for pregnant, lactating, and elderly patients?
What first‑line oral medication for type 2 diabetes, known to cause significant diarrhea, is the patient most likely taking?
How should I assess and initially manage a patient presenting with wrist pain or suspected wrist pathology?
Are zaleplon and suvorexant Schedule IV controlled substances for an adult with mild insomnia who is not taking serotonergic medications and has no contraindications such as eosinophilia‑myalgia syndrome, severe hepatic disease, pregnancy, or breastfeeding?
Is surgery indicated for a disc protrusion?
In a 12‑year‑old patient diagnosed with type 2 diabetes mellitus, which oral medication is the most appropriate initial therapy?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question