Assessment and Management of Headache
Initial Red-Flag Evaluation
Immediately evaluate for life-threatening secondary causes before assuming a primary headache disorder. Critical red flags requiring urgent investigation include 1, 2, 3:
- Thunderclap headache (sudden, severe onset reaching maximum intensity within seconds to minutes)
- New headache after age 50 years
- Headache awakening patient from sleep or present upon awakening
- Rapidly increasing frequency or severity of headache
- Focal neurologic signs or symptoms (weakness, sensory loss, visual field defects, dysarthria, ataxia)
- Papilledema or signs of increased intracranial pressure
- Persistent headache following head trauma
- Headache with fever, neck stiffness, or altered mental status (suggesting meningitis)
- Headache in patients with cancer, HIV/AIDS, or immunosuppression
- Headache provoked by Valsalva maneuvers or postural changes
Diagnostic Workup for Red Flags
When red flags are present, obtain noncontrast CT scan immediately to rule out hemorrhage, followed by lumbar puncture if CT is normal to evaluate for subarachnoid hemorrhage, infection, or CSF pressure abnormalities 3. MRI is superior for posterior fossa pathology and detailed structural evaluation but is less widely available 3.
Diagnosis of Primary Headache Disorders
Migraine Diagnosis
Suspect migraine in patients with recurrent moderate-to-severe headaches, visual aura, family history, or symptom onset around puberty 1. Migraine is characterized by 1, 2, 4:
- Moderate to severe throbbing/pulsating pain lasting 4-72 hours
- Unilateral location (though can be bilateral)
- Accompanied by nausea, vomiting, photophobia, or phonophobia
- Aggravated by routine physical activity
- Visual aura in ~30% of patients (fortification spectra, scintillating scotomas spreading gradually over ≥5 minutes)
Chronic migraine is defined as ≥15 headache days per month for >3 months, with ≥8 days having migraine features 1.
Tension-Type Headache Diagnosis
Tension-type headache presents with 2, 4:
- Bilateral, pressing or tightening quality
- Mild to moderate intensity
- Not aggravated by routine physical activity
- Lacks nausea, vomiting, or significant photophobia/phonophobia
Acute Treatment Algorithm
For Mild to Moderate Migraine
Start with NSAIDs as first-line therapy: aspirin 900-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 500-550 mg 1. The combination of acetaminophen 250 mg + aspirin 250 mg + caffeine 65 mg is also effective 1.
Critical pitfall: Acetaminophen alone is ineffective for migraine 1.
For Moderate to Severe Migraine
Use triptans as second-line therapy when NSAIDs fail or for initially severe attacks 1, 2. Effective triptans include 1:
- Sumatriptan: 50-100 mg oral, 6 mg subcutaneous (fastest onset), or 20 mg intranasal
- Rizatriptan: 10 mg oral
- Naratriptan: 2.5 mg oral (slower onset, longer duration)
- Zolmitriptan: 2.5-5 mg oral
Triptans eliminate pain at 2 hours in 20-30% of patients but cause transient flushing, tightness, or tingling in 25% 4. Contraindications include cardiovascular disease, uncontrolled hypertension, basilar or hemiplegic migraine 1.
For insufficient triptan response, combine with a fast-acting NSAID 1, 2.
Third-Line Acute Options
Gepants (CGRP receptor antagonists) such as rimegepant or ubrogepant eliminate headache at 2 hours in 20% of patients, with nausea and dry mouth in 1-4% 4. Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 4.
Adjunctive Therapy
Add antiemetics (metoclopramide or prochlorperazine) for nausea and vomiting 2.
Tension-Type Headache Acute Treatment
Use ibuprofen 400 mg or acetaminophen 1000 mg for acute tension-type headache 1.
Preventive Therapy Indications
Consider preventive therapy when patients have 1, 2:
- ≥2 attacks per month producing disability lasting ≥3 days per month
- Contraindication to or failure of acute treatments
- Use of abortive medication >2 times per week (to prevent medication overuse headache)
- Patient preference for prevention over acute treatment
First-Line Preventive Medications
For episodic migraine, start with 1:
- Beta-blockers: Propranolol 80-240 mg/day or timolol 20-30 mg/day
- Topiramate: 50-100 mg/day (especially beneficial in obese patients)
- Angiotensin-receptor blockers: Candesartan or lisinopril
Other first-line options include magnesium and memantine 1.
Second-Line Preventive Medications
Amitriptyline 10-100 mg at bedtime or nortriptyline for patients with coexisting anxiety or depression 1, 5.
Valproate is effective but absolutely contraindicated in women of childbearing potential due to teratogenicity 1, 5.
Third-Line Preventive Medications
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) for patients failing first- and second-line agents 1, 5. These reduce migraine by 1-3 days per month relative to placebo 4.
OnabotulinumtoxinA 155-195 units every 12 weeks is FDA-approved for chronic migraine prevention only, not episodic migraine 1, 5.
Chronic Tension-Type Headache Prevention
Use amitriptyline for prevention of chronic tension-type headache 1.
Special Populations
Older Adults
Secondary headache, comorbidities, and adverse events are all more likely in older patients 1. Poor evidence base exists for all drugs in this age group 1. Giant cell arteritis must be excluded in new-onset headache after age 50 6, 3.
Children and Adolescents
Presentation can differ from adults; bed rest alone can be sufficient 1. Use ibuprofen for acute treatment and propranolol, amitriptyline, or topiramate for prevention 1.
Pregnant or Breastfeeding Women
Use paracetamol (acetaminophen) for acute treatment 1. Avoid preventive treatment if possible 1.
Treatment Response Evaluation
Use headache calendars to track frequency, severity, and medication use 1. Assess effectiveness and adverse events after 2-3 months at therapeutic dose for oral preventives 5. Consider pausing treatment after 6-12 months of successful control 5.
When outcomes are suboptimal, review diagnosis, treatment strategy, dosing, and adherence before changing therapy 1.
Medication Overuse Headache Prevention
Limit simple analgesics to <15 days/month and triptans to <10 days/month 5. Discourage medication overuse and recognize established overuse early 1. For medication overuse headache, withdraw overused medication, preferably abruptly 1.
Critical pitfall: Ergotamines, opioids, and barbiturates carry high risk for medication overuse headache and dependency; avoid these agents 1, 5.
Comorbidity Management
Identify and manage modifiable risk factors including obesity, medication overuse, caffeine use, obstructive sleep apnea, anxiety, depression, and stress 5. Alleviate comorbidities to improve headache outcomes 1.
Non-Pharmacologic Interventions
Physical therapy or aerobic exercise can be used for both tension-type headache and migraine management 1. Biobehavioral therapy, including relaxation techniques, stress management, and biofeedback, can be as effective as pharmacological approaches 5.