Headache
Basics
Primary or Secondary?
1st question - onset
Hyperacute→ think vascular
Acute/subacute→ broader ddx
Chronic→ reassure if unchanged
Use SNOOP4 for screen secondary causes
-Pain features - "SOCRATES"
> quality (throbbing, pressure, stabbing)
> duration & frequency
> associated sx (photo/phonophobia, N/V, auto sx)
*open-ended, avoid anchoring
*migraine term is freq 'mis'used
*reverse-HA hx, ask
"How many days per month do you NOT have HA?"
≠ bad vs mild HAs
>medication use freq
What NOT to miss
-GCA→ ESR/CRP, visual changes, chew
-IIH→ worse laying, pulsatile tinnitus, visual obscuration, VI palsy
-CVST→ focal neurological sx, pointing sign
-IHypo→ worse standing, post-LP
-RCVS→ recur thunderclap; stimulant, marijuana
-MOH→ Vit A (seal liver), decongestant
Primary etiologies
-Migraine→ U/L, pulsatile, photo/phonophobia, aura, nausea
-TTH→ B/L, pressure-like
-TACs→ tear, rhinorrhea, ptosis
> cluster, PH, SUNCT/ SUNA, HC
-Others (Ten list)
> cough, exercise, sexual, thunderclap, cold, external-pressure, stabbing, nummular, hypnic, NDPH
Non-HA mimics
-Sinusitis
-TMJ dysfunction
-Cervicogenic pain
-Refractive errors
-Neuralgias
Physical exam
-Fundoscopy - papilledema
-CN - vision, facial pain, diplopia
-Weakness or sensory loss
-Meningeal signs
-Touch head, s/f tender & triggers
>TMJ, OCN, cervical, MSK (traps)
Work-up
NO imaging, if all
-HA is clearly migraine or TTH
-Normal NE
-Long-stand stable pattern
-No red flags
Order imaging, if
- ⊕SNOOP4 screen
Do LP, if
-C/f IIH; check OP
-High c/f SAH w/ ⊖ CTH; check RBC
-C/f infection, inflammatory, neoplastic
Management
-Aim near-full improvement (last guideline 2025), before 50%
*Caution: improvement w/ meds do NOT define if HA is 1st or 2nd
Inpatient
HA cocktail
-Hydration + sleep (benadryl & compazine) + antiemetics (metoclopramide) + IV Mg +/- NSAIDs (ketorolac 30q8, max 5d)
*order standing
- if refractory:
> MTP 125 mcg 1x/d for 5 d
> VPA 500q8h for 5d
-DHE
> 1mg IV, max 3 mg/d
> need telemetry; check EKG, avoid if CAD or aura
Outpatient
Acute/ abortive
- OTC (ibuprofen, acetaminophen)
* adv freq and MOH
-Triptans
> sumatriptan 50q2hr; max 200 mg/d
> if PO fails→ nasal/ SC
> adv max dose and avoid CAD
-Gepants (nurtec, qulipta, ubrelvy)
> Nurtec & qulipta can acute&prev
> Ubrelvy 50-100 q2h, max 200
-Fioricet (butalbital–acetaminophen–caffeine)
> avoid, high-risk MOH, HA ≤2 d/mo
Preventive
Consider when > 2 HAs/wk
-Supplements
-TCA
-BB/ CCB
-ASMs
-CGRPs
-Botox
Lifestyle
-Avoid triggers (advised the pt to observe)
-Healthy diet
-Sleep, hydration, exercise, and avoid stress
-Moderate caffeine
Pt education
-Set expectations: trial-and-error is normal
-Emphasize early use of abortive meds
-Avoid medication overuse
-Encourage HA diary
>day, features, medication
