Population: Adults with headache.

Organizations

ICSI 2011, NICE 2022, ACR 2022

Recommendations

Evaluation

–Take a detailed history (characteristics of headache, functional impairment, past medical and family history, current and previous medications including over-the-counter used for headache, and social history and review of systems to help rule out systemic illness) and perform a focused physical and neurologic exam.

–Be alert for any causes for concern:

• Subacute and/or progressive over months.

• New or different headache.

• “Worst headache ever.”

• Headache most severe at onset.

• Onset after age 50.

• Symptoms of systemic illness.

• Seizures.

• Any neurologic signs.

–Consider headache diary ×8 wk including frequency/duration/severity, any associated symptoms, medications taken, possible precipitants, and relationship to menstruation.

–Primary headaches can include migraine, tension-type, cluster, chronic daily headache, sinus-type,¹ or other.

• Tension-type: bilateral, pressing/tightening, mild-moderate, not aggravated by routine ADLs, variable duration.

• Migraine: unilateral or bilateral, pulsating/throbbing/banging, moderate-severe, aggravated by or causes avoidance of routine ADLs, photophobia or phonophobia, aura (flickering lights, spots/lines in vision, numbness/pins-needles, speech disturbance), lasts 4–72 h.

• Cluster headache: unilateral (around eye/above eye/alongside of face), variable quality, severe, causes restlessness/agitation, ipsilateral red/watery eye, nasal congestion, eyelid swelling, forehead/facial swelling, constricted pupil, lasts 15–180 min.

– Approach to imaging (ACR)

• No imaging:

Uncomplicated headaches.

New primary migraine or tension-type headache, normal neurologic exam.

Initial assessment of chronic headache, without new features or neurologic deficit.

• Urgent red flag symptoms require prompt evaluation:

Signs of systemic illness in the patient with new-onset headache.

New headache in patients over 50 y of age with symptoms of temporal arteritis.

Papilledema in an alert patient without focal neurological signs.

An older patient with new headache and subacute cognitive change.

• Emergent red flag symptoms require immediate emergency department evaluation:

Onset of sudden, severe headache (seconds to a minute to a peak onset of intensity).

Headache with fever and neck stiffness.

Papilledema with altered level of consciousness and/or focal neurological signs.

• Consider imaging or specialty consultation if:

Atypical headaches.

Changes in headache pattern.

Unexplained focal signs in the patient with a headache.

Headache precipitated by exertion, postural change, cough, or valsalva.

New-onset cluster headache or another trigeminal autonomic cephalgia, hemicrania continua, or new daily persistent headache.

• Specific neuroimaging recommendations for complicated headache. In patients with:

Sudden, severe headache reaching maximum severity within an hour, evaluate with CT head without IV contrast for initial imaging.

New headache and optic disc edema, evaluate with MRI head without and with IV contrast, MRI head without IV contrast, or CT head without IV contrast for the initial imaging. These procedures are equivalent alternatives.

New or progressively worsening headache with one or more of the following “red flags”: subacute head trauma, related activity or event (sexual activity, exertion, positional), neurological deficit, known or suspected cancer, immunosuppressed or immunocompromised state, age 50 y or older, evaluate with CT head without IV contrast, MRI head without and with IV contrast, or MRI head without IV contrast for the initial imaging. These procedures are equivalent alternatives. Pregnancy is also considered a “red flag” condition, with separate considerations for radiation and contrast exposure, typically avoiding CT scans.

New primary headache of suspected trigeminal autonomic origin (cluster headache), obtain MRI head without and with IV contrast for the initial imaging.

Chronic headache presenting with new features or increasing frequency, evaluate with MRI head without and with IV contrast or MRI head without IV contrast for the initial imaging. These procedures are equivalent alternatives.

Management

–If no cause for concern found and headache meets criteria for primary headache disorder: initiate education, treatment, and lifestyle modification recommendations.

–If cause for concern is found, consider specialty consultation and perform any indicated diagnostic testing. If findings consistent with secondary headache, refer to alternate guideline.

–Treatment of tension-type headache:

• Give acetaminophen, aspirin, NSAID, or adjunctive therapy for acute headache.

• If unsuccessful, consider other treatment, reconsider diagnosis, and consider medication overuse.

• For frequent headaches, consider prophylactic treatments: amitriptyline or other TCA, venlafaxine. If prophylaxis unsuccessful, consider specialty referral.

–Treatment of cluster headache:

• Acute: oxygen (100% FiO₂, ≥12 L/min), sumatriptan SQ, dihydroergotamine.

• Bridging treatment: corticosteroids, ergotamine, occipital nerve block.

• Maintenance treatment: verapamil. Avoid alcohol. Progress to high-dose verapamil, steroids, lithium, depakote or topiramate if needed.

Sources

–Beithon J et al. Diagnosis and Treatment of Headache. Updated 2011.

–www.nice.org.uk/guidance/cg150

–American College of Radiology Appropriateness Criteria Headache, revised 2022. http://www.choosingwisely.org/societies/american-college-of-radiology/