Evaluation and Management of Headaches

Initial Assessment and Red Flags

Evaluate for sudden onset/thunderclap headache, which may indicate subarachnoid hemorrhage, and assess for headache that worsens when lying down or bending over, which may suggest increased intracranial pressure, as recommended by the American College of Physicians 1
Determine if headache is worsened by Valsalva maneuver, which increases suspicion for secondary causes, according to the American Academy of Family Physicians 2
Note if headache awakens the patient from sleep, is of new onset in an older person, or is progressively worsening, which are concerning features, as noted by the American Academy of Family Physicians 3
Check for neurological deficits, which may indicate stroke, hemorrhage, or mass lesion, as recommended by the American College of Physicians 1

Neuroimaging should be considered in patients with nonacute headache that has worsened and persisted for 2 months, according to the American Academy of Family Physicians 2
Non-contrast head CT is the first-line imaging study in the emergency department setting, as recommended by the American College of Physicians 1
If the headache has atypical features or does not meet the strict definition of migraine, a lower threshold for neuroimaging should be applied, according to the American Academy of Family Physicians 2

Consider chronic migraine diagnosis if patient has ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria, as defined by the American Headache Society 4, 5
Medication overuse headache should be considered, defined as headache occurring on 15 or more days per month for at least 3 months due to overuse of acute medication, according to the American College of Physicians 6
The threshold for medication overuse headache varies by treatment (≥15 days/month with NSAIDs; ≥10 days/month with triptans), as noted by the American College of Physicians 6

For acute treatment in the ED, consider NSAIDs, acetaminophen, or combination therapy for mild headache, as recommended by the American Academy of Family Physicians 6, 7
For moderate to severe headache, consider triptans (sumatriptan 50-100 mg) if no contraindications exist, according to the American College of Physicians 6
Consider antiemetics like metoclopramide or prochlorperazine for accompanying nausea and as adjunctive therapy for pain, as recommended by the American Academy of Family Physicians 7, 3
Avoid opioids and butalbital for treatment of acute headache, as recommended by the American College of Physicians 6

Advise the patient to maintain a headache diary to track frequency, severity, and medication use, as recommended by the American Headache Society 5
Recommend lifestyle modifications including hydration, regular meals, sufficient sleep, physical activity, and stress management, according to the American College of Physicians 6
Consider referral to neurology or headache specialist for ongoing management, especially if diagnosis of chronic migraine is suspected, as recommended by the American Headache Society 8
Educate about medication overuse headache and the importance of limiting acute medications, as noted by the American College of Physicians 6, 9