Headache Management in Adults

Initial Evaluation and Diagnosis

The American Academy of Family Physicians suggests that critical red flags requiring immediate neuroimaging and urgent evaluation include thunderclap onset, new headache after age 50, progressive worsening pattern, headache awakening patient from sleep, and worsening with Valsalva maneuver 2, 1
Focal neurologic signs or symptoms are a red flag for secondary headache disorders, according to the American Academy of Family Physicians 3
The presence of scalp tenderness, jaw claudication, or fever may indicate giant cell arteritis or infection, respectively 2, 1

The American Academy of Family Physicians recommends asking specific diagnostic questions to classify the headache type, including location, character, intensity, duration, associated symptoms, aggravating factors, and medication use 3

The American College of Radiology suggests that neuroimaging is not necessary if the patient has a normal neurologic examination, features consistent with primary headache disorders, and a long history of similar headaches without pattern change 1
MRI with and without contrast is recommended if any red flag symptoms are present, or if there are abnormal neurologic examination findings or atypical headache patterns 2, 1, 3

The American Headache Society recommends first-line treatment with NSAIDs, such as ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 500-1000 mg, for migraine or tension-type headache 4, 5
Second-line treatment with triptans, such as oral sumatriptan, rizatriptan, zolmitriptan, or naratriptan, is recommended if NSAIDs fail after adequate trial 4
Antiemetics, such as metoclopramide 10 mg or prochlorperazine 10 mg, are recommended for nausea and vomiting 4, 5

The American Academy of Neurology recommends starting preventive therapy if the patient has ≥2 attacks per month producing disability lasting ≥3 days, or if acute treatment is required >2 days per week 4, 5, 1
First-line preventive options include beta-blockers, such as propranolol 80-240 mg/day, antiepileptics, such as topiramate, and tricyclic antidepressants, such as amitriptyline 30-150 mg/day 4, 2, 5

The American Academy of Neurology recommends avoiding opioids as routine headache therapy due to dependency risk, rebound headaches, and limited efficacy 1
Preventive medications should be started at low doses and titrated slowly over 2-3 months to assess efficacy 4, 2

The American Headache Society recommends tracking frequency, severity, triggers, and medication use with a headache diary, and evaluating treatment response within 2-3 months 1, 2
Consider tapering preventive therapy after a period of stability, and refer to neurology for cluster headaches, uncertain diagnosis, poor response to preventive strategies, or headache with motor weakness 4, 1