What are the recommended evaluation and management steps for a patient with an eight‑year history of persistent headaches?

Evaluation and Management of Eight-Year Persistent Headaches

For a patient with persistent headaches spanning eight years (2018–2026), this represents chronic daily headache requiring immediate assessment for medication-overuse headache, followed by specialist referral and initiation of evidence-based preventive therapy if primary headache is confirmed.

Initial Red-Flag Assessment

Before proceeding with chronic headache management, you must systematically exclude secondary causes that demand urgent intervention:

• Rule out progressive intracranial pathology: Any headache that has progressively worsened over this eight-year period, awakens the patient from sleep, or is precipitated by Valsalva maneuver warrants MRI brain with and without contrast 1, 2.
• Exclude giant cell arteritis: If the patient is over 50 years old (onset in 2018 would make this relevant if currently ≥58 years), obtain ESR and CRP immediately, recognizing that 10–36% of giant cell arteritis cases have normal ESR 1.
• Assess for meningitis or infection: Any unexplained fever, neck stiffness, or altered mental status requires emergency referral within 1 hour 2.
• Screen for thunderclap features: Abrupt-onset severe headache suggests subarachnoid hemorrhage and mandates non-contrast CT if presenting within 6 hours (95% sensitivity) 1.

If any red flag is present, refer to emergency department immediately before proceeding with chronic headache evaluation 1, 2.

Determine Primary Headache Type

With red flags excluded, characterize the headache pattern using a headache diary over 4 weeks to establish frequency, duration, and features 1:

Chronic Migraine Criteria

• ≥15 headache days per month for >3 months (clearly met over 8 years) 3, 1
• ≥8 days per month meeting migraine criteria: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity, plus nausea/vomiting or both photophobia and phonophobia 1, 2
• If these criteria are met, the diagnosis is chronic migraine 3

Chronic Tension-Type Headache

• Bilateral, pressing/tightening (non-pulsating) pain of mild-to-moderate intensity 1, 2
• Lacks nausea/vomiting and the combination of photophobia plus phonophobia 1
• Not aggravated by routine physical activity 1

Medication-Overuse Headache (Critical Pitfall)

This is the most common reason for treatment failure in chronic headache and must be identified first 3:

• ≥15 headache days per month with regular overuse of non-opioid analgesics (aspirin, acetaminophen, NSAIDs) on ≥15 days/month for >3 months 1, 2
• OR any other acute medication (triptans, ergots, combination analgesics, opioids) on ≥10 days/month for >3 months 1, 2
• Many patients do not consider over-the-counter analgesics as "real" medications, leading to under-recognition 1

If medication-overuse headache is present, preventive therapy will fail unless the overused medication is withdrawn first 3.

Management Algorithm

Step 1: Address Medication-Overuse Headache First

If MOH is identified:

• Educate the patient about the risk of perpetuating headache with frequent acute medication use 3
• Abrupt withdrawal is preferred for all medications except opioids (which require tapering) 3
• Explain that headache may temporarily worsen for 2–10 days before improvement begins 3
• Do not initiate preventive therapy until after withdrawal, as MOH renders preventive medications ineffective 3

Step 2: Refer to Specialist Care

All patients with chronic migraine (≥15 headache days/month for >3 months) should be referred to neurology 3:

• Referral is indicated for diagnosis confirmation, preventive therapy initiation, and management of refractory cases 2, 4
• Non-urgent referral (within 2–4 weeks) is appropriate if no red flags are present 1

Step 3: Initiate Evidence-Based Preventive Therapy

Once MOH is ruled out or successfully treated, initiate preventive medication 3:

First-Line Options for Chronic Migraine

The only medications with robust evidence in chronic migraine are 3:

1. Topiramate: First choice due to lower cost; also preferred if obesity is present (associated with weight loss) 3
2. OnabotulinumtoxinA: Proven effective in chronic migraine 3
3. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Proven beneficial in patients who have failed ≥2 other preventive medications 3

Important caveat: Beta-blockers (propranolol), candesartan, and amitriptyline lack robust randomized controlled trial data for chronic migraine, though they are commonly used in clinical practice 3. However, amitriptyline is preferred if depression or sleep disturbances are comorbid 3.

For Chronic Tension-Type Headache

• Amitriptyline is the first-line preventive agent, with evidence supporting its use in chronic tension-type headache 1

Step 4: Identify and Manage Comorbidities

Chronic headache is strongly associated with 3:

• Anxiety and depression: More pronounced in chronic migraine than episodic 3
• Sleep disturbances: Consider amitriptyline if present 3
• Obesity: A risk factor for chronification; topiramate is preferred 3
• Chronic pain conditions (neck pain, lower back pain): Address these to improve headache outcomes 3

Adjust treatment choice based on comorbidity profile to maximize benefit and minimize adverse effects 3.

Step 5: Acute Treatment Strategy

While establishing preventive therapy, provide acute treatment with strict limits to prevent MOH recurrence 2, 5:

• NSAIDs or acetaminophen: First-line for mild-to-moderate attacks 1, 5
• Triptans: For moderate-to-severe attacks or when NSAIDs fail; eliminate pain in 20–30% by 2 hours but avoid in cardiovascular disease 5
• Gepants (rimegepant, ubrogepant): Alternative for patients with cardiovascular risk factors; eliminate pain in 20% by 2 hours 5
• Lasmiditan (5-HT1F agonist): Safe in cardiovascular disease 5
• Limit acute medication use to <10 days per month for triptans/ergots and <15 days per month for simple analgesics to prevent MOH recurrence 3, 1

Step 6: Long-Term Follow-Up

• Primary care should assume long-term management once sustained efficacy with preventive therapy is achieved for 6 months with no substantial adverse effects 3
• Emphasize patient education and self-efficacy; avoid routine scheduled visits unless necessary for repeat prescriptions 3
• Instruct the patient to return if headache pattern changes, preventive therapy loses efficacy, or new concerning features develop 3, 2

Common Pitfalls to Avoid

• Ordering neuroimaging for typical chronic migraine with normal neurological examination: This adds cost without changing management and is not indicated 1, 6
• Starting preventive therapy before addressing MOH: Preventive medications will fail if MOH is present 3
• Assuming all persistent headaches are migraine: Eight years of daily headache may represent chronic tension-type headache, which requires different management 1
• Missing giant cell arteritis in patients >50 years: This can cause permanent vision loss if untreated 1, 7
• Allowing unlimited acute medication use: This perpetuates the chronic headache cycle 3

Summary of Algorithmic Approach

1. Exclude red flags → Emergency referral if present 1, 2
2. Diagnose medication-overuse headache → Withdraw overused medication before preventive therapy 3
3. Classify primary headache type (chronic migraine vs. chronic tension-type) using diary 1
4. Refer to neurology for all chronic migraine cases 3
5. Initiate topiramate (first-line for chronic migraine) or amitriptyline (for chronic tension-type or if depression/sleep disturbance present) 3, 1
6. Identify and treat comorbidities to optimize outcomes 3
7. Limit acute medication use to prevent MOH recurrence 3
8. Transfer back to primary care after 6 months of sustained efficacy 3