What does a nurse practitioner need to know about diagnosing and managing headaches, particularly migraine, in a primary care setting?

Essential Knowledge for NPs Managing Headache and Migraine in Primary Care

As a nurse practitioner in primary care, you must recognize that up to 75% of patients presenting with headache complaints actually have migraine, and your role is critical for accurate diagnosis, appropriate treatment initiation, and timely specialist referral when needed. 1

Epidemiology You Need to Know

• Headache accounts for 1 in 10 primary care consultations, making it one of the most common complaints you'll encounter 1
• Migraine prevalence is approximately 15% in women and 6% in men, peaking at age 40 years 1
• 1-5% of headache patients will have chronic migraine, which carries substantially greater disability and economic burden than episodic migraine 1
• Only 20% of patients meeting chronic migraine criteria are correctly diagnosed, highlighting a critical diagnostic gap you must address 1

Your Diagnostic Approach: A Stepwise Algorithm

Step 1: Rule Out Secondary Headache with Red Flags

First, evaluate for red flags that mandate immediate neuroimaging (preferably MRI, CT if unavailable): 2

• Sudden "thunderclap" onset (peaking within 1 second to 1 minute)
• Headache awakening patient from sleep
• Focal neurologic deficits (weakness, visual changes, gait abnormality)
• New headache after age 50
• Progressively worsening headache over days to weeks
• Fever or signs of infection
• Worsening with Valsalva maneuver (coughing, straining, bending)
• Papilledema or abnormal neurological examination

A completely normal neurologic examination permits management as primary headache without imaging. 2

Step 2: Distinguish Chronic from Episodic Migraine

Ask this specific question: "Do you feel like you have a headache of some type on 15 or more days per month?" 1

Chronic migraine diagnostic criteria: 1

• ≥15 headache days/month for >3 months
• ≥8 days/month meet migraine criteria (with or without aura) OR respond to migraine-specific treatment
• Each headache lasts ≥4 hours if untreated

Episodic migraine: <15 headache days/month 1

Status migrainosus: Single migraine attack lasting >72 hours 2

Critical pitfall: Patients often report only their "severe headache days" and fail to mention milder headache days—you must specifically ask about ALL headache days 1

Step 3: Confirm Migraine Features

Migraine requires at least 2 of these characteristics: 2

• Unilateral location
• Throbbing/pulsatile quality
• Worsening with routine physical activity

PLUS associated symptoms: 2

• Nausea/vomiting OR
• Both photophobia AND phonophobia

Distinguish from tension-type headache, which requires: 2

• At least 2 of: pressing/tightening quality, bilateral/diffuse location
• BOTH absence of nausea/vomiting AND lack of simultaneous photophobia + phonophobia

Step 4: Implement Headache Diary

Have patients maintain a headache diary to track symptomatic days and acute medication use—this facilitates accurate diagnosis, detects medication overuse, and monitors treatment response 1, 2

Your Acute Treatment Strategy

First-Line Acute Therapy

Start with NSAID + antiemetic: 2

• Naproxen 500-825 mg at onset, repeat q2-6h up to 1.5 g/day
• Ibuprofen 400-800 mg q6h
• Aspirin + acetaminophen + caffeine for moderate-to-severe attacks

When to Escalate to Triptans

Escalate to triptans after 3 consecutive attacks fail to respond to NSAIDs—different triptans may be tried sequentially 2

If all triptans fail, consider ditans or gepants 2

Critical Medication-Overuse Warning

Limit acute medication to ≤2 days/week (≤10 days/month) to prevent medication-overuse headache, which is a much greater risk in chronic migraine 2, 3

Your Preventive Therapy Algorithm

Who Needs Preventive Therapy

All patients with chronic migraine (≥15 headache days/month) should be considered for pharmacological prophylaxis 3

First-Line Preventive Options

Choose from these evidence-based first-line agents: 2

1. Beta-blockers: Propranolol 80-160 mg daily (long-acting), metoprolol, atenolol, or bisoprolol
2. Topiramate (titrate slowly to minimize side effects)
3. Candesartan (angiotensin-II receptor blocker)

Second-Line Options

If first-line agents fail or are not tolerated: 2

• Amitriptyline
• Flunarizine
• Do NOT use sodium valproate in women of childbearing potential (contraindicated)

Third-Line Options Requiring Specialist Initiation

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) are reserved for patients who have failed or cannot tolerate earlier preventives 2

OnabotulinumtoxinA has the best evidence for efficacy in chronic migraine and should be available to patients as necessary, typically requiring specialist administration 3

When to Refer to Neurology

Mandatory Specialist Referrals

Refer immediately for: 2

• Cluster headaches (complex treatment requirements)
• Headache with motor weakness (e.g., hemiplegic migraine)
• Migraine with persistent aura
• Uncertain diagnosis after thorough primary care evaluation
• Poor response to adequate trials of multiple evidence-based preventives
• Chronic migraine meeting criteria (≥15 headache days/month for >3 months with migraine features on ≥8 days)

Do not unduly delay specialist referral for refractory chronic migraine—these patients require specialized treatments including onabotulinumtoxinA or CGRP antibodies 3

When Primary Care Management is Appropriate

You can manage without referral when: 2

• Typical migraine or tension-type headache with normal neurological examination and no red flags
• Episodic migraine responding to acute treatment with NSAIDs or triptans
• Long history of similar headaches without pattern change and normal examination
• Stable, well-controlled headaches with regular monitoring

Your Follow-Up Protocol

Re-evaluate patients 2-3 months after initiating preventive therapy to assess: 2

• Headache frequency
• Pain intensity
• Disability level
• Medication adverse effects

React promptly to any change in headache pattern that may warrant re-referral 2

Critical Pitfalls to Avoid

1. Do not dismiss week-long or prolonged headaches as "simple tension"—duration alone mandates preventive therapy 2

2. Do not continue ineffective acute treatments indefinitely—after 3 failed NSAID trials, step up to triptans 2

3. Do not order neuroimaging in the absence of red flags or abnormal examination—it adds cost without altering management 2

4. Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 2

5. Recognize medication overuse headache in patients taking analgesics >10 days/month—these patients may need specialist referral for detoxification 2

6. Do not fail to ask about ALL headache days—patients underreport milder headache days, leading to missed chronic migraine diagnoses 1

Understanding the Disability Impact

Chronic migraine causes severe disability including inability to work, attend social functions, and perform routine chores—this substantially impacts quality of life and justifies aggressive treatment and even short-term disability consideration when appropriate 1, 4

Your role as the first point of contact is essential for identification, appropriate treatment initiation, and managing patient care between specialist appointments, making you a critical partner in the comprehensive management of these highly disabled patients 1