CLINICAL PRINTABLE
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A one-page Headache clinical reference is on the way.
1 · Recognition / Alarm Features
- Primary headaches (no underlying structural cause): migraine (most common disabling headache), tension-type (most common overall), cluster headache (rare, severe, unilateral periorbital). Secondary headaches: caused by an underlying condition — must be excluded before diagnosing primary headache.
- SNOOP4 red flags for secondary headache: Systemic symptoms (fever, weight loss, HIV/cancer), Neurologic symptoms or signs, Onset sudden (thunderclap), Onset after age 50, Progressive worsening, Postural component, Precipitated by Valsalva, Papilledema. Any of these warrants urgent evaluation.
- Thunderclap headache: maximal intensity within 60 seconds. Subarachnoid hemorrhage (SAH) until proven otherwise. CT head without contrast (sensitivity ~98% within 6 hours of onset). If CT negative, lumbar puncture for xanthochromia. Do not dismiss thunderclap headache as migraine.
- Migraine features: unilateral, pulsating, moderate-to-severe intensity, aggravated by routine activity, associated with nausea/vomiting, photophobia, or phonophobia. Aura (visual, sensory, or speech disturbance) in 25–30% of migraineurs. Duration 4–72 hours untreated.
- Medication overuse headache (MOH): headache on ≥15 days/month in a patient using acute headache medications on ≥10–15 days/month. Triptans, opioids, combination analgesics. Paradoxically worsens with continued use. Treatment requires medication withdrawal.
2 · Differential / Secondary Causes
Subarachnoid hemorrhage (SAH)
Thunderclap headache — 'worst headache of my life.' Sudden onset, maximal at onset. Neck stiffness, photophobia, altered mental status. CT head (non-contrast) first. LP if CT negative. Neurosurgery consultation.
Meningitis / encephalitis
Headache + fever + neck stiffness (Kernig's/Brudzinski's signs) + photophobia. Altered mental status suggests encephalitis. LP for CSF analysis. Empiric antibiotics (ceftriaxone + vancomycin + dexamethasone) before LP if bacterial meningitis is suspected and LP will be delayed.
Temporal arteritis (giant cell arteritis)
Age >50, new headache, temporal artery tenderness, jaw claudication, elevated ESR/CRP. Risk of irreversible vision loss. Start prednisone 40–60 mg/day immediately — do not wait for biopsy results. Temporal artery biopsy within 2 weeks.
Idiopathic intracranial hypertension (IIH)
Obese women of childbearing age. Daily headache, pulsatile tinnitus, transient visual obscurations, papilledema. Elevated opening pressure on LP (>25 cmH2O). Acetazolamide, weight loss, serial LPs. Ophthalmology for visual field monitoring.
Cervicogenic headache
Headache originating from cervical spine structures. Unilateral, non-pulsating, associated with neck pain and restricted cervical range of motion. Worsened by neck movement. Physical therapy and cervical nerve blocks.
3 · Treatment Pathway
Migraine — acute treatment
Mild-to-moderate: NSAIDs (ibuprofen 400–800 mg, naproxen 500–1000 mg) or acetaminophen. Moderate-to-severe: triptans (sumatriptan, rizatriptan, eletriptan) — most effective when taken early. Combination: sumatriptan/naproxen. Antiemetics (metoclopramide, prochlorperazine) for nausea and as adjuncts. Avoid opioids — increase risk of MOH and chronification.
Migraine — preventive treatment
Indicated when: ≥4 migraine days/month, significant disability, acute medication overuse, or contraindication to acute treatments. First-line: topiramate, valproate, propranolol, metoprolol, amitriptyline. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): highly effective, well-tolerated, for refractory migraine.
Tension-type headache
Bilateral, pressing/tightening (non-pulsating), mild-to-moderate intensity, not aggravated by routine activity, no nausea/vomiting. Acetaminophen or NSAIDs for acute treatment. Amitriptyline for prevention of chronic tension-type headache. Stress management, sleep hygiene, physical therapy.
Cluster headache
Severe unilateral periorbital/temporal pain, 15–180 minutes, with ipsilateral autonomic features (lacrimation, rhinorrhea, ptosis, miosis). Occurs in clusters (weeks to months). Acute: 100% oxygen (7–12 L/min for 15 minutes) or subcutaneous sumatriptan. Prevention: verapamil (first-line), lithium, topiramate.
Medication overuse headache (MOH)
Withdraw the overused medication. Abrupt withdrawal for triptans and NSAIDs. Gradual taper for opioids and barbiturates. Expect worsening headache for 2–10 days during withdrawal. Bridge therapy: NSAIDs, prednisone taper, or dihydroergotamine (DHE). Start preventive therapy simultaneously.
4 · Expected Response
- Triptans: onset of relief within 2 hours in 60–70% of patients. Take early in the migraine attack for best effect.
- CGRP monoclonal antibodies: 50% reduction in monthly migraine days in 50–60% of patients. Full effect at 3 months.
- MOH withdrawal: headache frequency typically improves significantly within 2 months of successful withdrawal.
- Temporal arteritis: visual symptoms should not progress after starting prednisone. Taper guided by ESR/CRP normalization over months to years.
5 · Escalation
- Thunderclap headache: CT head immediately. If CT negative, LP for xanthochromia. Neurosurgery consultation for SAH.
- Headache with fever, neck stiffness, or altered mental status: empiric antibiotics and LP for meningitis/encephalitis.
- New headache in patient >50 with elevated ESR/CRP and temporal artery tenderness: start prednisone immediately for temporal arteritis — do not wait for biopsy.
- Status migrainosus (migraine lasting >72 hours): IV fluids, IV prochlorperazine or metoclopramide, IV ketorolac, IV DHE. Consider short-course prednisone.
Apply It · Change One Detail
APPLY IT
A 32-year-old woman presents with a 4-hour unilateral throbbing headache with nausea and photophobia, similar to prior episodes. She has had 3 similar headaches this month. This is migraine. Treat acutely with a triptan. Discuss preventive therapy given frequency (≥4 days/month). Ask about acute medication use frequency — if she is using triptans or NSAIDs >10 days/month, she may already have medication overuse headache.
CHANGE ONE DETAIL
Change one detail — a 58-year-old woman presents with a new severe headache, right temporal artery tenderness, jaw pain when chewing, and ESR of 95. This is temporal arteritis until proven otherwise. Start prednisone 60 mg/day immediately — do not wait for biopsy. Delay risks irreversible vision loss. Refer to rheumatology and ophthalmology. Temporal artery biopsy within 2 weeks.
Bottom Line
Thunderclap headache is SAH until proven otherwise — CT head immediately, then LP if CT is negative. New headache in a patient >50 with elevated inflammatory markers and temporal artery tenderness is temporal arteritis — start prednisone before the biopsy.
EVIDENCE & REFERENCES
- Silberstein SD, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012;78(17):1337-1345. doi:10.1212/WNL.0b013e3182535d20
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi:10.1177/0333102417738202
- Hunder GG, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990;33(8):1122-1128. doi:10.1002/art.1780330810