Approach to Patient with Headache

Initial Evaluation and Red Flags

The initial evaluation of any patient presenting with headache must prioritize ruling out secondary causes through careful assessment for "red flags" before diagnosing and managing primary headache disorders, as recommended by the American Academy of Neurology 1, 2
Thunderclap headache, which is a sudden onset headache peaking within 1 second to 1 minute, suggests subarachnoid hemorrhage and requires urgent evaluation 2
New headache after age 50 requires urgent assessment for temporal arteritis, mass lesions, or other serious pathology, according to the American Geriatrics Society 2, 3
Headache worsened by Valsalva maneuver, such as coughing, straining, or bending, suggests increased intracranial pressure 2, 3
Headache awakening patient from sleep may indicate increased intracranial pressure or serious secondary cause, as noted by the American Academy of Sleep Medicine 2, 3
Progressively worsening headache over days to weeks suggests evolving pathology, as indicated by the American Headache Society 2, 3
Fever or signs of infection with headache requires urgent evaluation for meningitis or encephalitis, as recommended by the Infectious Diseases Society of America 2
Abnormal neurological examination findings mandate immediate imaging and specialist evaluation, according to the American Academy of Neurology 2, 3
Focal neurological deficits or motor weakness necessitate neurological evaluation to exclude serious secondary causes, as noted by the American Stroke Association 2, 4

Chronic migraine is diagnosed when a patient experiences 15 or more headaches per month, each at least 4 hours in duration, with migraine features on 8 or more days per month, as defined by the International Headache Society 1, 3, 5
Episodic migraine is characterized by fewer than 15 headache days per month, with acute treatment options including NSAIDs, acetaminophen, or triptans, as recommended by the American Academy of Neurology 3
Cluster headache is diagnosed based on severe unilateral pain lasting 15-180 minutes with ipsilateral autonomic symptoms, occurring 1-8 times daily in clusters, as defined by the International Headache Society 4
Tension-type headache is characterized by bilateral, pressing/tightening quality, mild to moderate intensity, and lacks autonomic features, as noted by the American Headache Society 4

Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine, as indicated by the American Academy of Neurology 1, 5, 6
OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis, as recommended by the FDA 1, 5, 6
Referral to neurology is recommended for all cluster headaches, chronic migraine, and headache with motor weakness, as noted by the American Academy of Neurology 2

Neuroimaging is indicated when any red flags are present, unexplained abnormal findings on neurologic examination, or atypical features that don't fit established primary headache patterns, as recommended by the American College of Radiology 2, 3
MRI brain is the preferred imaging modality when indicated, as noted by the American Academy of Neurology 4
Referral to neurology is recommended for patients with chronic migraine, cluster headache, or headache with motor weakness, as indicated by the American Academy of Neurology 2