What is the recommended approach to evaluating and managing a headache, including acute and preventive treatment options?

Approach to Headache Evaluation and Management

Initial Evaluation: Distinguishing Primary from Secondary Headache

The cornerstone of headache diagnosis is identifying "red flags" that suggest secondary causes requiring urgent evaluation, while recognizing that most headaches are primary disorders (migraine or tension-type) that can be safely managed in the outpatient setting. 1, 2

Red Flags Requiring Urgent Evaluation

• Sudden onset ("thunderclap") headache 2, 3
• New headache onset after age 50 4, 2
• Progressive worsening pattern or increased frequency/severity 5, 2
• Abnormal neurologic examination findings 5, 2
• Headache with systemic illness (fever, weight loss) or in immunocompromised/cancer patients 2
• Headache worsening with Valsalva maneuver or awakening from sleep 5
• Papilledema on examination 2
• Headache following head trauma 2

Neuroimaging Indications

• Obtain MRI brain for any red flag features, atypical presentations, or abnormal neurologic examination 4, 5
• Non-contrast CT followed by lumbar puncture if thunderclap headache to rule out subarachnoid hemorrhage 2
• Check ESR and CRP in patients >50 years with new headache to exclude giant cell arteritis 4, 6

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Primary Headache Disorders: Classification and Diagnosis

Migraine

Suspect migraine in patients with recurrent moderate-to-severe headaches, especially with visual aura, family history, and onset around puberty. 1

Diagnostic Features:

• Visual aura (fortification spectra) in >90% of those with aura 1
• Sensory symptoms (unilateral paresthesia spreading gradually) in ~31% 1
• Associated symptoms: photophobia, phonophobia, nausea/vomiting 1, 5
• Duration: 2-72 hours in adults (can be 2-72 hours in children) 1
• Chronic migraine: ≥15 headache days per month for >3 months 1

Tension-Type Headache

• Episodic tension-type headache: bilateral, pressing/tightening quality, mild-to-moderate intensity 1
• Chronic tension-type headache: ≥15 days per month 5
• No significant associated symptoms (unlike migraine) 1

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Acute Treatment Strategies

Migraine: Stepped Care Approach

First-line acute treatment consists of NSAIDs plus antiemetic if necessary, taken at headache onset. 1

Step 1: NSAIDs

• Ibuprofen 400-800 mg 1, 5
• Naproxen sodium 500-825 mg 5
• Diclofenac potassium 1
• Aspirin-acetaminophen-caffeine combination (acetaminophen alone is ineffective for migraine) 5, 7

Step 2: Triptans (if NSAIDs fail after 3 consecutive attacks)

• Triptans eliminate pain in 20-30% at 2 hours 7
• Adverse effects: transient flushing, tightness, tingling in 25% 7
• Contraindicated in patients with cardiovascular disease due to vasoconstrictive properties 1, 7
• Switch to different triptan if suboptimal response 1
• Combine with fast-acting NSAIDs when triptans provide insufficient relief 1

Step 3: Gepants or Ditans (if all triptans fail)

• Rimegepant 75 mg: achieves pain freedom at 2 hours in 21.2% vs 10.9% placebo 8
• Ubrogepant: eliminates headache in 20% at 2 hours 7
• Adverse effects: nausea, dry mouth in 1-4% 7
• Lasmiditan (5-HT1F agonist): safe in patients with cardiovascular risk factors 7

Tension-Type Headache: Acute Treatment

• Ibuprofen 400 mg (first-line) 1, 5
• Acetaminophen 1000 mg (first-line) 1, 5
• Avoid acetaminophen 500-650 mg (inadequate analgesia) 5

Critical Pitfall: Medication Overuse Headache

Limit acute medication use to ≤2 days per week or maximum 10 days per month to prevent medication overuse headache. 6

• Suspect medication overuse in patients with daily headaches taking frequent analgesics 4, 6
• Verify over-the-counter medication use directly 4
• Withdraw overused medication abruptly when medication overuse headache is established 1

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Preventive Treatment

When to Initiate Preventive Therapy

Consider preventive treatment in patients adversely affected by migraine on ≥2 days per month despite optimized acute treatment. 1, 5

Episodic Migraine Prevention

First-Line Medications:

• Beta-blockers: propranolol, metoprolol, atenolol, bisoprolol 1, 5
• Topiramate 1, 6
• Candesartan (angiotensin-receptor blocker) 1
• Lisinopril 1
• Magnesium 1

Second-Line Medications:

• Flunarizine 1
• Amitriptyline 1
• Sodium valproate (in men only; absolutely contraindicated in women of childbearing potential) 1
• Memantine 1

Third-Line: CGRP Monoclonal Antibodies

• Indicated when first/second-line preventives fail or are contraindicated 1
• Atogepant 60 mg daily: reduces migraine days by 0.8 days/month vs placebo 9
• Rimegepant 75 mg every other day: reduces migraine days by 0.8 days/month vs placebo 8

Medications NOT Recommended:

• Gabapentin: not recommended for episodic migraine prevention 1

Chronic Migraine Prevention

• OnabotulinumtoxinA: effective for chronic migraine prevention 1
• NOT recommended for episodic migraine 1
• CGRP monoclonal antibodies: atogepant 60 mg daily reduces migraine days by 1.8 days/month vs placebo in chronic migraine 9

Chronic Tension-Type Headache Prevention

• Amitriptyline 50-100 mg daily (only medication with consistent evidence) 1, 5
• Start low dose and titrate based on response 5
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention), especially in older adults 5
• OnabotulinumtoxinA NOT recommended for tension-type headache 5

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Non-Pharmacologic Therapies

Consider non-pharmacologic therapies as adjuncts to medication or as stand-alone treatment when medication is contraindicated. 1

Evidence-Supported Interventions:

• Aerobic exercise 1
• Physical therapy 1
• Biobehavioral therapy 1
• Acupuncture (though not superior to sham) 1
• Non-invasive neuromodulatory devices 1

Insufficient Evidence:

• Isolated biofeedback, cognitive-behavioral therapy, mindfulness, or progressive muscle relaxation for tension-type headache 5

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Special Populations

Children and Adolescents

• Bed rest alone may suffice for short-duration attacks 1
• Acute treatment: ibuprofen (first-line) 1
• Prevention: propranolol, amitriptyline, or topiramate 1
• Assess menstrual relationship in adolescent females 5
• Consider short-term NSAID prophylaxis 2-3 days before expected menses if menstrual pattern emerges 5

Pregnant or Breastfeeding Women

• Acute treatment: acetaminophen (paracetamol) 1
• Avoid preventive treatment if possible 1

Older Adults (>50 years)

• Higher suspicion for secondary causes 1
• Monitor blood pressure regularly if using triptans 1
• More susceptible to adverse effects 1
• Poor evidence base for all drugs in this age group 1

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Management Algorithm for Daily Headaches with Normal Workup

When MRI is normal and neurologic examination is unremarkable, determine whether the pattern represents chronic migraine, medication overuse headache, or chronic tension-type headache. 6

Immediate Steps:

1. Document medication use patterns (>10 days/month of analgesics/NSAIDs/triptans indicates overuse) 6
2. Initiate preventive therapy immediately (topiramate or propranolol) 6
3. Address medication overuse (preventive therapy will not work until overuse is eliminated) 6
4. Implement lifestyle modifications: limit caffeine, regular meals, adequate hydration, sleep hygiene, regular aerobic exercise, stress management 6

Follow-Up:

• Re-evaluate in 2-3 months to assess response 6
• Refer to neurology/headache specialist if poor response to two first-line preventives, worsening attacks, or atypical features 6

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Long-Term Management Principles

• Use headache calendars to track frequency and treatment response 1
• Assess effectiveness and adverse events regularly 1
• Review diagnosis, treatment strategy, dosing, and adherence when outcomes are suboptimal 1
• Manage comorbidities (depression, anxiety) to improve outcomes 1
• Maintain stability of effective treatment and react to changes 1
• Specialist referral indicated for chronic migraine, treatment failure after two preventives, or diagnostic uncertainty 1, 6