What is the appropriate evaluation and management for a 30‑year‑old woman with diffuse headaches lasting up to a week and no identified triggers?

Management of Diffuse Headaches Lasting Up to a Week in a 30-Year-Old Woman

This presentation most likely represents chronic migraine or chronic tension-type headache, and you should initiate preventive therapy immediately given the prolonged duration and frequency of symptoms, starting with first-line agents like propranolol, topiramate, or candesartan. 1

Initial Evaluation: Rule Out Red Flags First

Before classifying this as a primary headache disorder, systematically exclude secondary causes by asking about specific warning features:

• Sudden onset reaching peak intensity within 1 minute (thunderclap pattern) suggests subarachnoid hemorrhage or other vascular catastrophe 2, 3
• Headache awakening her from sleep may indicate increased intracranial pressure 1, 2
• Worsening with Valsalva maneuver (coughing, straining, bending) suggests increased intracranial pressure 2
• Progressively worsening pattern over days to weeks indicates evolving pathology 2
• Fever or signs of infection requires urgent evaluation for meningitis 2
• Focal neurologic symptoms (weakness, vision changes, coordination problems) mandate immediate imaging 1, 2
• New onset after age 50 would require urgent assessment, though this patient is 30 years old 2

If any of these red flags are present, obtain neuroimaging (MRI preferred, or CT if MRI unavailable) before proceeding with primary headache management. 1, 2

Perform Focused Neurologic Examination

A completely normal neurologic examination in the absence of red flags allows you to confidently manage this as a primary headache disorder without neuroimaging. 1, 2 Specifically examine for:

• Papilledema (suggests increased intracranial pressure) 1
• Focal motor or sensory deficits 1
• Coordination and gait abnormalities 1
• Neck stiffness (meningeal signs) 4

Classify the Headache Type

Likely Chronic Migraine or Chronic Tension-Type Headache

Given the diffuse location and week-long duration, ask about these specific features to differentiate:

For migraine diagnosis, she needs at least 2 of these characteristics: 1, 5

• Unilateral location (though diffuse doesn't exclude migraine)
• Throbbing/pulsatile character
• Moderate to severe intensity
• Worsening with routine physical activity

Plus at least 1 of these associated symptoms: 1, 5

• Nausea and/or vomiting
• Both photophobia AND phonophobia

For tension-type headache diagnosis, she needs at least 2 of these: 1, 5

• Pressing, tightening, or non-pulsatile character
• Mild to moderate intensity
• Bilateral/diffuse location
• No aggravation with routine activity

Plus both of these: 1, 5

• No nausea or vomiting (anorexia acceptable)
• Not both photophobia and phonophobia together (may have one)

Critical Point About Duration

Week-long headaches suggest either chronic migraine (≥15 headache days per month for >3 months with migraine features on ≥8 days) or status migrainosus (migraine attack lasting >72 hours). 1, 2 This prolonged pattern itself indicates need for preventive therapy regardless of exact classification.

Acute Treatment Strategy

First-Line Acute Treatment

Start with NSAIDs plus antiemetic if nausea is present: 1, 5

• Naproxen sodium 500-825 mg at headache onset, can repeat every 2-6 hours (maximum 1.5 g/day) 6
• Ibuprofen 400-800 mg every 6 hours 5
• Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 6

Escalate to Triptans if NSAIDs Fail

If three consecutive attacks fail to respond to NSAIDs, switch to triptans: 1

• Try different triptans sequentially if the first one is suboptimal 1
• Consider ditans or gepants only after all available triptans have failed 1

Critical Medication Overuse Warning

Limit acute treatment to no more than 2 days per week (or 10 days per month) to prevent medication-overuse headache. 6, 5 Overuse creates a vicious cycle of increasing headache frequency leading to daily chronic headaches. 6 Given her week-long headaches, she is at extremely high risk for this complication.

Preventive Therapy: The Priority Intervention

Given that her headaches last up to a week at a time, she clearly meets criteria for preventive therapy and you should initiate it immediately. 1 The indication is being adversely affected by migraine on ≥2 days per month despite optimized acute treatment. 1

First-Line Preventive Options (Choose One)

• Propranolol 80-160 mg daily (long-acting formulation) 1, 6
• Metoprolol, atenolol, or bisoprolol (other beta blockers without intrinsic sympathomimetic activity) 1
• Topiramate (titrate slowly to minimize side effects) 1
• Candesartan 1

Second-Line Options if First-Line Fails

• Amitriptyline 1
• Flunarizine 1
• Sodium valproate (strictly contraindicated in women of childbearing potential, so NOT appropriate for this 30-year-old woman) 1

Third-Line Options

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) are reserved for patients in whom other preventive drugs have failed or are contraindicated. 1 These typically require specialist initiation. 2

Non-Pharmacological Adjuncts

Consider adding these alongside medication: 1

• Neuromodulatory devices (evidence-supported)
• Biobehavioral therapy (evidence-supported)
• Acupuncture (some evidence, though not superior to sham)

Note that physical therapy and dietary approaches have little to no supporting evidence. 1

Follow-Up and Monitoring Strategy

Re-evaluate within 2-3 months to assess: 6

• Attack frequency and duration
• Pain intensity and disability
• Adverse effects from medications
• Treatment adherence

Have her maintain a headache calendar tracking symptomatic days and acute medication use to monitor for medication overuse and treatment response. 6

When to Refer to Neurology

This patient can be managed in primary care if: 2

• Neurologic examination remains normal
• She responds to preventive therapy
• No red flags develop

Refer to neurology if: 2

• Uncertain diagnosis after thorough evaluation
• Poor response to adequate trials of multiple evidence-based preventive therapies
• Development of any red flag features
• Pattern changes significantly

Common Pitfalls to Avoid

• Don't dismiss week-long headaches as "just tension headaches" – this duration and pattern demands preventive therapy 1
• Don't continue ineffective acute treatments indefinitely – use the stepped care approach and escalate after three failed attacks 1
• Don't allow unlimited acute medication use – strictly limit to prevent medication-overuse headache 6, 5
• Don't delay preventive therapy – she already meets clear criteria given the prolonged duration and likely frequency 1
• Don't order neuroimaging without red flags or abnormal examination – this increases costs without changing management 1, 2