Headache

Background

• Headache is a common clinical problem that arises in a variety of healthcare situations and is a leading cause of disability worldwide and in the United States.
• Headache disorders are broadly categorized as either primary headaches (not attributed to another disorder) or secondary headaches (caused by another underlying disorder) by the International Classification of Headache Disorders, 3rd ed. (ICHD-3).
• Patients with a history of headache who do not have red flags are at low risk of serious headache.
• The 3 key outpatient situations in which headache presents differ in approach based on the likelihood of secondary headache and specific management issues:
  • In the outpatient office setting, most headaches are common primary headaches (such as migraine or tension-type headache) or the secondary headache disorder medication overuse headache.
  • In the emergency department (ED), the role of the provider is to exclude immediately life-threatening headache and to provide safe and effective treatment of acute symptoms.
  • Patients with headaches during pregnancy are a special population and require specific evaluation and management strategies.
• Headache led to almost 4 million emergency room visits in the United States in 2014.

Evaluation

• SNNOOP10 criteria may be helpful in identifying red flags suggestive of a secondary cause of headache
  • Systemic symptoms including fever - suggestive of infection or nonvascular intracranial disorder, carcinoid, or pheochromocytoma; orange flag for isolated headache
  • Neoplasm in history - suggestive of brain neoplasm or metastasis
  • Neurologic deficit - suggestive of headaches attributable to vascular or nonvascular intracranial disorders, brain abscess, or other infections
  • Onset of headache is sudden or abrupt - suggestive of subarachnoid hemorrhage and other headaches attributable to cranial or cervical vascular disorders
  • Older age (age > 50 years) - suggestive of giant cell arteritis or other headaches attributable to cranial or cervical vascular disorders, neoplasms, and other nonvascular intracranial disorders
  • Pattern change or recent onset of headache - suggestive of neoplasms and headaches attributable to vascular or nonvascular intracranial disorders
  • Positional headache - suggestive of intracranial hypertension or hypotension
  • Precipitated by sneezing, coughing, or exercise - suggestive of posterior fossa malformations or Chiari malformation
  • Papilledema - suggestive of intracranial hypertension, neoplasms, and other nonvascular intracranial disorders
  • Progressive headache and atypical presentations - suggestive of neoplasms and other nonvascular intracranial disorders
  • Pregnancy or puerperium - suggestive of headaches attributable to cranial or cervical vascular disorders, postdural puncture headache, hypertension-related disorders (such as preeclampsia), cerebral sinus thrombosis, hypothyroidism, anemia, or diabetes
  • Painful eye with autonomic features - suggestive of Tolosa-Hunt syndrome, ophthalmic causes, or pathology in posterior fossa, pituitary region, or cavernous sinus
  • Posttruamatic onset of headache - suggestive of acute and chronic posttaumatic headache, subdural hematoma, and other headaches attributable to vascular disorders
  • Pathology of immune system such as with HIV infection - suggestive of opportunistic infections
  • Painkiller overuse or use of new drug at onset of headache - suggestive of medication overuse headache or drug incompatibility
• In the outpatient office setting, the history is targeted to defining common primary headache syndromes (migraine, tension-type headaches, cluster headache) and assessing for red flags suggesting potential secondary headache syndromes requiring further evaluation and referral.
  • Perform further evaluation if SNNOOP10 questions are positive, suggesting secondary causes of headache.
  • In patients with stable headaches, normal neurologic examination, and no other "red-flag" features, diagnostic imaging is typically not required.
• In the emergency room, evaluate for secondary causes of headache:
  • Ask about mode of onset of headache, exertion causing headache, focal neurologic symptoms, and concurrent medical illnesses.
  • Examine for meningismus, papilledema on fundoscopy, palpation of sinuses, temporomandibular joint, and carotid and temporal pulses.
  • Perform Emergency Department Diagnostic Testing if SNNOOP10 questions are positive and consider cerebrospinal fluid testing for meningitis or encephalitis.
    • Noncontrast computed tomography (CT) of head is the initial study of choice in most cases.
    • CT angiography (CTA) may be helpful to rule out dissection.
    • With new-onset headache, perform CT of head early to rule out subarachnoid hemorrhage as CT approaches 100% sensitivity for subarachnoid hemorrhage (SAH) within 6-12 hours of onset progressively declining over 5 days to 58%.
  • Consider lab testing including routine labs, sedimentation rate, and reactive protein in patients > 50 years old for giant cell arteritis (previously referred to as temporal arteritis).
  • Perform lumbar puncture to evaluate for red blood cells and xanthochromia if CT is negative for SAH but it is highly clinically suspected (for example with thunderclap headache or new worst headache).
• Perform initial diagnostic imaging tests as indicated.
  • For patients with sudden-onset, severe headache that reaches maximal severity within one hour, perform CT of head without contrast.
  • For patients with primary trigeminal cephalalgias, perform MRI of head without then with contrast.
  • For patients with features of intracranial hypertension (such as papilledema, pulsatile tinnitus, or visual symptoms worse on Valsalva), perform either CT of head without IV contrast, MRI of head without IV contrast, or MRI without then with IV contrast.
  • For patients with features of intracranial hypotension, perform MRI of head without then with IV contrast.
  • For patients with ≥ 1 red-flags features (increasing frequency or severity, fever or neurologic deficit, history of cancer or immunocompromise, age of onset > 50 years, or posttraumatic onset), perform either MRI of the head without contrast, MRI of head without then with IV contrast, or CT of head without contrast.
• In pregnant patients with a new onset of headache, sudden-onset severe headache, rapidly increasing headache frequency or severity, or neurologic deficits, diagnostic imaging should be considered early to rule out secondary causes of headache.
  • Perform MRI or CT of head without contrast. If contrast-enhanced evaluation of dural venous sinuses is needed, consider CT venography of head with iodinated contrast agent, which may be safer for fetus than gadolinium-based contrast agents.
  • For acute stroke, perform workup as per usual acute stroke with caution as to risks of diagnostic testing for both mother and the fetus.

Management

• Most patients seen in an office practice have migraine or tension-type headache.
  • Avoid prolonged or frequent use of over-the-counter (OTC) pain medications for headache due to the risk of complications, including medication overuse headache.
  • Medication overuse headache is common in the office and an important cause of failure of headache treatment.
  • Treatment is directed at the specific type of headache disorder. See:
    • Tension-type Headache
    • Migraine in Adults
    • Migraine in Children and Adolescents
    • Cluster Headache and other trigeminal autonomic cephalalgias
    • Medication Overuse Headache
    • Postdural Puncture Headache
    • Trigeminal Neuralgia
  • Refer for neuroimaging and specialty evaluation for suspected secondary causes of headache.
• In the ED, when secondary causes of headache are found in evaluation, the treatment is primarily focused on treatment of the specific cause.
  • When secondary headaches and rare primary headaches have been ruled out, management of severe migraine becomes the focus.
    • Most patients will have tried aspirin, acetaminophen, and other nonsteroidals before ED visit, and most will have nausea requiring treatment.
    • A variety of medications have been used in the ED setting for acute headache such as ketorolac 30-60 mg intramuscularly, sumatriptan 6 mg subcutaneously, chlorpromazine 25-50 mg IV, divalproex sodium 500-1,000 mg in 50 mg normal saline IV over 30 minutes, magnesium 1-2 g IV over 10-30 minutes, and dexamethasone 4-10 mg IV.
• For pregnant patients with headache, the general goal is to avoid medications (particularly early in pregnancy) and during breastfeeding due to a concern about exposure-related teratogenicity or toxicity.
  • Nonpharmacologic treatments to consider include the avoidance of triggers such as sleep deprivation, skipping meals, emotional stress, balanced lifestyle with physical exercise, and regular eating and sleep habits.
  • Consider acupuncture and behavioral therapies.
  • When using pharmacologic treatments, aim for the lowest effective dose and shortest duration of treatment.
  • Acetaminophen is considered the safest pharmacologic option in pregnancy but may increase risk of asthma and attention deficit hyperactivity disorder (ADHD) in children.
  • For management of migraine in pregnant patients, see Migraine - Treatment of Acute Attack in Adults.
  • For acute headache management options include:
    • IV magnesium 1 g IV over 10-30 minutes, which may repeat up to maximum 5 g
    • IV hydration
    • occipital nerve block
  • For pharmacologic prevention of headaches, consider beta-blockers or tricyclic antidepressants at the lowest effective dose.
  • Medications are considered safe during breastfeeding if the relative infant dose is < 10%.
  • For specific treatments of secondary headaches in pregnancy, see
    • Hypertensive Disorders of Pregnancy
    • Cerebrovascular Complications of Pregnancy
    • Cerebral Venous Thrombosis (CVT) in Adults
    • Idiopathic Intracranial Hypertension