Evaluation and Management of Headache

Initial Assessment

The American Academy of Family Physicians recommends assessing onset characteristics, duration, frequency, and location of headache, as well as evaluating pain characteristics, associated symptoms, aggravating/relieving factors, and medication use in patients with headache 3, 1
The American College of Physicians suggests documenting presence of aura symptoms, family history, and potential triggers in patients with headache 1, 4
A headache that awakens a patient from sleep may indicate increased intracranial pressure, according to the American Headache Society 2
The American Academy of Neurology recommends asking if headache is worsened by Valsalva maneuver, which may suggest secondary causes 2

The International Headache Society defines migraine without aura as at least 5 attacks lasting 4-72 hours with 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, 1
The American Academy of Neurology defines migraine with aura as at least 2 attacks with reversible aura symptoms developing gradually over ≥5 minutes, each lasting 5-60 minutes, followed by headache within 60 minutes 1

The American College of Radiology recommends neuroimaging for patients with unexplained abnormal findings on neurological examination, headache worsened by Valsalva maneuver, or headache that awakens patient from sleep 4, 2
The American College of Radiology suggests that MRI is preferred over CT due to higher resolution and absence of radiation exposure 2

The American Academy of Neurology recommends considering prophylaxis if headaches occur more than twice weekly, with evidence-based options including antihypertensives, antiepileptics, antidepressants, CGRP monoclonal antibodies, and onabotulinumtoxinA 4, 1

The American Headache Society recommends avoiding overuse of acute headache medications (use >10 days per month) which can lead to medication overuse headache 4
The American Academy of Neurology suggests referring patients to a specialist for cluster headaches, uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with motor weakness 4