Headache Assessment and Management

Initial Assessment

The American Academy of Family Physicians recommends identifying red flags for secondary headaches, including sudden onset ("thunderclap") headache, new headache after age 50, progressively worsening headache, headache awakening patient from sleep, and headache worsened by Valsalva maneuver 1, 2
A thorough key history elements assessment should include onset, duration, frequency, and location of headache, as well as pain characteristics, associated symptoms, aura symptoms, aggravating and relieving factors, medication use, family history, and triggers 3, 4, 5

The International Headache Society recommends the following diagnostic criteria for migraine without aura: at least 5 attacks lasting 4-72 hours, at least two of unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity, and at least one of nausea/vomiting, photophobia and phonophobia 5, 3
The International Headache Society also recommends the following diagnostic criteria for migraine with aura: at least 2 attacks with reversible aura symptoms, aura symptoms develop gradually over ≥5 minutes, each aura symptom lasts 5-60 minutes, and aura followed by headache within 60 minutes 5
The American Academy of Neurology recommends the following diagnostic criteria for tension-type headache: bilateral location, pressing/tightening quality, mild to moderate intensity, no aggravation with routine activity, and no nausea or vomiting 3, 6

The American College of Radiology recommends neuroimaging for patients with unexplained abnormal findings on neurological examination, headache worsened by Valsalva maneuver, headache that awakens patient from sleep, new onset headache in older adults, and progressively worsening headache 1, 2, 8

The American Headache Society recommends the following goals of treatment: rapid and consistent relief of headache, restoration of patient's ability to function, minimizing use of backup and rescue medications, optimizing self-care, cost-effective management, and minimal or no adverse effects 8
The American Academy of Neurology recommends acute treatment for mild to moderate migraine with non-narcotic analgesics, NSAIDs, and combination products with caffeine, and monitoring for medication overuse headache 8, 5
The American Headache Society recommends preventive treatment for patients with ≥2 headaches per week or chronic migraine, including antihypertensives, antiepileptics, antidepressants, CGRP monoclonal antibodies, and onabotulinumtoxinA 7

The International Headache Society recommends detoxification and implementation of appropriate preventive therapy for medication overuse headache 5, 7
The American Academy of Neurology recommends prophylactic medications, including topiramate, for chronic migraine management, and consideration of referral to headache specialist for difficult-to-manage cases 7