How should I assess and manage a headache, including red‑flag evaluation and treatment options for tension‑type and migraine?

Management of Headache

Initial Red Flag Assessment

Screen every headache patient for dangerous secondary causes using the SNNOOP10 criteria before proceeding with primary headache management. 1

Critical red flags requiring immediate evaluation include:

• Thunderclap headache (subarachnoid hemorrhage) 1
• Progressive headache or new onset after age 50 (space-occupying lesion, temporal arteritis) 1
• Headache with fever and neck stiffness (meningitis) 1
• Focal neurological deficits (stroke, mass lesion) 1
• Atypical aura (TIA, stroke—distinguished from migraine aura by sudden simultaneous onset vs. gradual spread over ≥5 minutes) 1
• Headache worsened by Valsalva, coughing, or position changes (intracranial hypertension/hypotension) 1

Neuroimaging is indicated only when secondary headache is suspected based on red flags, not routinely for primary headaches. 1

Diagnosis: Migraine vs. Tension-Type Headache

Migraine Characteristics

• Moderate to severe intensity, often unilateral and pulsating 1
• Associated with nausea/vomiting, photophobia, and phonophobia 1
• May include visual aura (fortification spectra in >90% of aura cases, spreading gradually over ≥5 minutes) 1
• Family history common, typically onset around puberty 1

Tension-Type Headache Characteristics

• Bilateral, pressing/tightening quality (non-pulsating) 2
• Mild to moderate intensity 2
• No significant nausea or vomiting 2
• May have photophobia OR phonophobia, but not both 2

Use a headache diary to document frequency, symptoms, triggers, and treatment response—this is essential for accurate diagnosis and monitoring. 3

Acute Treatment for Migraine

First-Line: NSAIDs

Offer NSAIDs as initial therapy: ibuprofen, diclofenac potassium, or acetylsalicylic acid (aspirin). 1 These should be taken early when headache is still mild for maximum effectiveness. 1

Second-Line: Triptans

When NSAIDs fail, offer triptans—all triptans have well-documented effectiveness. 1 Key points:

• Take early in the headache phase (when pain is mild), NOT during aura 1
• If one triptan fails, try others—individual response varies 1
• For rapid peak intensity or vomiting, use sumatriptan subcutaneous injection 1
• Combine triptans with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) to prevent relapse 1

Third-Line: CGRP Inhibitors (Gepants)

For patients who fail all triptans or have contraindications, use gepants (ubrogepant or rimegepant). 1 These newer CGRP inhibitors are effective alternatives but have limited availability globally. 4

Adjunct Therapy

Add prokinetic antiemetics (metoclopramide or domperidone) for nausea and vomiting. 1

Medications to Avoid

Never use oral ergot alkaloids (poorly effective and toxic), opioids (questionable efficacy, high dependency risk), or barbiturates (significant adverse effects). 1 Hydromorphone IV must not be offered in emergency settings. 5

Acute Treatment for Tension-Type Headache

Use ibuprofen 400 mg or acetaminophen 1000 mg for acute TTH episodes. 1 These are the evidence-based first-line options for episodic tension-type headache.

Preventive Treatment for Episodic Migraine

Offer preventive therapy to patients with ≥2 days per month of disabling migraine despite optimized acute treatment. 1

Evidence-Based Preventive Options (in order of consideration):

1. Topiramate (first choice due to cost-effectiveness) 1
2. Angiotensin-receptor blockers or lisinopril 1
3. Magnesium 1
4. Valproate (absolutely contraindicated in women of childbearing potential) 1
5. Memantine 1
6. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
7. Atogepant (oral gepant for prevention) 1

Do NOT use gabapentin for episodic migraine prevention—it is not recommended. 1

Do NOT use onabotulinumtoxinA for episodic migraine—it is only effective for chronic migraine. 1

Preventive Treatment for Chronic Migraine

Chronic migraine is defined as ≥15 headache days per month for >3 months. 1 These patients typically require specialist referral. 1

Evidence-based preventive options:

• Topiramate (first choice) 1
• OnabotulinumtoxinA 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1

Preventive Treatment for Chronic Tension-Type Headache

Use amitriptyline for prevention of chronic TTH—it has the strongest evidence. 1, 2

Medication Overuse Headache (MOH)

Suspect MOH in any patient with frequent headaches (≥15 days/month) who uses acute medications regularly. 3 This is a critical pitfall that transforms episodic headaches into chronic, intractable pain.

Management of MOH:

• Educate patients that frequent use of acute medications (>10 days/month for triptans, >15 days/month for simple analgesics) causes MOH 1
• Withdraw the overused medication—abrupt withdrawal is preferred except for opioids, barbiturates, and benzodiazepines 1
• Opioids, barbiturates, and benzodiazepines require slow tapering, possibly inpatient treatment 3
• Evidence is mixed on whether to start preventive therapy (like topiramate) during withdrawal 3

Non-Pharmacologic Interventions

Offer physical therapy or aerobic exercise for both migraine and TTH management. 1 These evidence-based interventions should be integrated into comprehensive treatment plans.

Greater occipital nerve blocks (GONB) must be offered for acute migraine treatment in the emergency setting. 5 Supraorbital nerve blocks (SONB) should also be offered. 5

Emergency Department Management

For parenteral therapy in the ED:

• Prochlorperazine IV must be offered (level A evidence) 5
• Dexketoprofen IV, ketorolac IV, metoclopramide IV, and sumatriptan SC should be offered 5
• Add dexamethasone IV to reduce headache recurrence 6, 5
• Provide IV fluids if dehydration is present 6
• Propofol IV and paracetamol IV should not be offered (likely ineffective) 5

Follow-Up and Monitoring

Schedule regular follow-up visits to assess treatment effectiveness, adverse events, and adherence using headache diaries. 3 When outcomes are suboptimal, review diagnosis, treatment strategy, dosing, and adherence before changing therapy. 1

Address comorbidities (depression, anxiety, sleep disturbances, obesity, chronic pain) as they significantly impact treatment outcomes. 1 Tailor medication choices to comorbidities: topiramate for obesity (causes weight loss), amitriptyline for depression/sleep issues. 1

Return patients from specialist care to primary care once stable on preventive therapy for 6 months with no significant adverse effects. 1