Approach to Headache Diagnosis and Management

Initial Assessment and Red Flag Identification

The American Academy of Neurology recommends immediately ruling out life-threatening secondary causes using red flag criteria, then systematically differentiating between primary headache disorders through targeted history and examination 1, 2
Thunderclap headache suggests subarachnoid hemorrhage, and new-onset headache after age 50 raises concern for temporal arteritis, mass lesion, or other secondary causes 1
Progressive worsening headache suggests intracranial space-occupying lesion, and headache with fever and neck stiffness indicates possible meningitis or subarachnoid hemorrhage 1
Focal neurological symptoms or signs suggest stroke, mass lesion, or other structural pathology, and recent head or neck trauma raises concern for subdural hematoma 1
Headache provoked by Valsalva, cough, exertion, or postural changes suggests intracranial hypertension/hypotension or structural lesion 1
Headache with altered consciousness, memory changes, personality changes, or weight loss indicates secondary pathology 1

The International Headache Society recommends that migraine without aura requires at least 5 lifetime attacks meeting specific criteria, including duration, location, quality, intensity, and associated symptoms 5, 6
Chronic migraine is diagnosed when headache occurs ≥15 days/month for >3 months, and on ≥8 days/month, headache meets migraine criteria or responds to triptan/ergot derivative 4, 5, 6
Tension-type headache is characterized by bilateral location, pressing/tightening quality, mild-to-moderate intensity, and absence of nausea or vomiting 5, 3
Medication-overuse headache is suspected when headache ≥15 days/month in patient with pre-existing headache disorder, and regular overuse of acute medication for >3 months 5

The American Headache Society recommends first-line acute treatment for migraine with NSAIDs (aspirin, ibuprofen, or diclofenac potassium) used early in the headache phase, and second-line treatment with triptans for patients not responding to NSAIDs 1
Gepants (rimegepant, ubrogepant) or ditans (lasmiditan) are recommended as third-line treatment options, and prokinetic antiemetics (domperidone or metoclopramide) are used as adjunct therapy for nausea/vomiting 1
Preventive treatment is considered when quality of life remains impaired despite optimized acute therapy, patients are adversely affected ≥2 days/month, or severe or prolonged attacks occur 1, 2, 3
Topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate are evidence-based options for prophylactic treatment of chronic migraine 2