Headache

Overview

  • Red flags

    • History and physical

      • New headache at age ≥ 50 years

      • Sudden onset, worse with position change, fever, malaise, myalgia, vision changes

      • Focal/lateralizing neurologic deficit on exam

    • Specific considerations

      • Intracranial hemorrhage (obtain STAT CT): Sudden onset, worse with position changes (e.g. supine vs. upright), new onset neurologic deficits

      • Intracranial mass (obtain MRI with contrast): Age ≥ 50 years with new onset neurologic deficit

      • Systemic symptoms, e.g. fever, malaise, myalgias: Consider infectious etiology (see below)

      • Elderly patient with fever, monocular visual loss, jaw claudication: Consider temporal arteritis

  • Treatment options

    • Non-pharmacologic

      • Home: Relaxation techniques and cervical exercises

      • Office: CBT, osteopathic manipulation, acupuncture

    • Pharmacologic options pending headache type

  • Consider neurology referral for refractory symptoms

Bilateral

Common

  • Tension headache

    • Bilateral band-like pressure that builds in intensity

    • Treatment options

      • Naproxen 550 mg BID

      • Acetaminophen 250 mg/aspirin 250 mg/caffeine 65 mg x 2 tablets

      • Reduction in frequency: Gabapentin 300 mg QHS; titrate to 300 mg TID as needed

      • Reduction in severity and duration: Amitriptyline 25 mg, tizanidine 2 mg TID (MDD 36 mg/day)

  • Medication withdrawal headache: Review caffeine, alcohol, and analgesic use; taper offending agent

  • Menstrual headache

Infectious

Uncommon

  • Emergent

    • Subarachnoid hemorrhage

    • Hypertensive encephalopathy

    • Preeclampsia

  • Benign intracranial hypertension

  • Carbon monoxide poisoning

Unilateral

  • Migraine

    • Pounding quality, duration 4-72 hours, unilateral, associated with nausea, and disabling

    • Avoid schedule changes, food/beverage triggers (e.g. caffeine and alcohol), environmental triggers

    • Abortive therapy with ibuprofen, sumatriptan

    • Four or more H/A per month: Prophylactic therapy with depakote, topiramate, propranolol, or amitriptyline

  • Cluster headache

    • Symptoms lasting 15 minutes to 3 hours

      • Unilateral orbital, supraorbital, or temporal pain

      • Autonomic phenomenon, e.g. ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea

    • Consider CT vs. MRI to r/o intracranial mass or other abnormalities

    • Acute treatment: One spray 20 mg intranasal sumatriptan in nostril on affected side (MDD 40 mg/24 hours)

  • Temporal (giant cell) arteritis

    • Associated with fever, monocular visual loss, jaw claudication

    • ESR 40 to 100

    • Refer for temporal artery biopsy and start prednisone 1 mg/kg (MDD 60 mg/day)

  • Hemiplegic (complicated) migraine

  • Intracranial mass