Headache Evaluation and Management

Initial Assessment

The American Academy of Family Physicians recommends evaluating for "red flags" that suggest secondary headache requiring urgent attention, including headache worsened by Valsalva maneuver, headache that awakens patient from sleep, and fever or signs of infection 2
The American Academy of Family Physicians suggests asking key diagnostic questions to determine headache type, including location, character, intensity, duration, and associated symptoms 2
The American Academy of Neurology recommends assessing for progressive worsening pattern, which may indicate a secondary headache disorder 3
The Mayo Clinic recommends evaluating the duration of headaches, which can help determine the type of headache disorder 1

The American Academy of Family Physicians indicates that neuroimaging is warranted when there are unexplained abnormal findings on neurologic examination, new onset in patients over 50 years, or atypical features that don't fit established primary headache patterns 2, 3
The American Academy of Neurology suggests that neuroimaging is generally not warranted for patients with normal neurologic examination, features consistent with primary headache disorders, or long history of similar headaches without change in pattern 3

The American Headache Society recommends considering prophylaxis if headaches occur more than twice weekly, with evidence-based options including topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate 1, 3
The American Academy of Neurology suggests that onabotulinumtoxinA is FDA-approved for chronic migraine prophylaxis 2
The International Headache Society defines chronic migraine as 15 or more headache days per month for more than 3 months, with migraine features on at least 8 days 1, 3

The American Academy of Family Physicians recommends avoiding medication overuse, which can lead to medication-overuse headache 1
The American Academy of Neurology suggests avoiding opioids for regular headache management due to risk of dependency and rebound headaches 4
The American Headache Society recommends considering referral to a neurologist for cluster headaches, uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with motor weakness 3, 5

The American Academy of Family Physicians recommends maintaining a headache diary to track frequency, severity, triggers, and treatment response 3
The American Academy of Neurology suggests identifying and avoiding personal triggers, establishing regular sleep patterns, and considering stress management techniques 1, 2, 4
The Mayo Clinic recommends understanding proper medication use to avoid rebound headaches 1