Headache Management

📚Definitions 

• Primary Headache: Headache without underlying pathology (migraine, tension-type, cluster)
• Secondary Headache: Symptom of another condition (infection, trauma, vascular disorders)
• Aura: Reversible neurological symptoms preceding/during migraine (visual, sensory, speech)

🗺️ Overview

This guideline provides evidence-based recommendations for the diagnosis and management of primary headache disorders in adults, including migraine, tension-type, and cluster headaches. It emphasizes identifying red flags that warrant urgent referral while supporting appropriate telehealth management of uncomplicated cases.

📹 Video Examination 

• Neurologic Screening:
  • Mental status evaluation
  • Cranial nerve assessment (facial symmetry, speech)
  • Motor strength (arm drift, heel/toe walking)

  • Sensory testing (light touch symmetry)

     

• Red Flag Identification:
  • Neck stiffness/resistance to flexion
  • Unilateral lacrimation/rhinorrhea (cluster)
  • Sinus tenderness
  • Blood pressure measurement (if possible)

  • Gait assessment (tandem walk, Romberg)

     

🎯 Differential Diagnosis 

Migraine

• Unilateral (70%) or bilateral throbbing pain
• Moderate-severe intensity
• Duration 4-72 hours
• Nausea/vomiting or photophobia/phonophobia
• ± Aura (visual, sensory, speech symptoms)

Tension-Type Headache

• Bilateral pressure/tightness
• Mild-moderate intensity
• No nausea/vomiting
• No photophobia/phonophobia (or only one)

Cluster Headache

• Severe unilateral orbital/temporal pain
• Duration 15-180 minutes
• Ipsilateral autonomic symptoms (tearing, nasal congestion)
• Restlessness/agitation during attacks

📩 Referral Indicators 

• Urgent:
  • "First/worst" headache of life
  • Thunderclap onset (peak intensity <1 minute)
  • New headache >50 years old
  • Progressive worsening pattern
  • Focal neurologic deficits
  • Altered mental status
  • Fever/neck stiffness
  • Headache awakening from sleep
  • Post-traumatic headache with confusion
  • Visual changes (acute vision loss, field defects)

  • Systemic symptoms (weight loss, jaw claudication)

     

• Non-Urgent

•  
  • Diagnostic uncertainty
  • Refractory symptoms
  • Need for preventive medications
  • Comorbid psychiatric conditions

💆 Treatment
 

Tension-Type Headache

• First-line:
  • Ibuprofen 400-800 mg q4-6h (max 3200 mg/day)

  • Acetaminophen 1000 mg q6h (max 4000 mg/day)

     

• If persistent:

  • Consider preventive strategies (stress management, physical therapy)

     

Migraine

• Early intervention:
  • NSAIDs (ibuprofen 800 mg initial dose)

  • Antiemetics if nausea present (ondansetron ODT 8 mg TID PRN)

     

• Moderate-severe attacks (for patients with established diagnosis):
  • Triptans (avoid >9 days/month):
    • Sumatriptan 50-100 mg PO (may repeat in 2h)

    • Rizatriptan 10 mg PO (may repeat in 2h)

       

  • Contraindications: CVD, uncontrolled HTN, basilar/hemiplegic migraine 

Cluster Headache

• Urgent referral for:
  • Oxygen therapy

  • Subcutaneous sumatriptan

     

• Preventive management requires in-person evaluation

Preventive Strategies

• Lifestyle modifications:
  • Regular sleep schedule
  • Hydration
  • Stress management

  • Trigger avoidance

     

• Medication overuse headache:

  • Limit acute medications to <15 days/month

     

• Requires taper of overused medications

 🔮 Follow Up 

• Schedule follow-up if:
  • New headache diagnosis
  • Suboptimal response to treatment
  • Medication adjustments needed

📘 Coding

ICD-10 Codes

• G43.909: Migraine, unspecified
• G44.209: Tension-type headache, unspecified
• G44.009: Cluster headache, unspecified
• R51.9: Headache, unspecified

If you have any questions or would like more information, please reach out to the Delegating Physician.