One-liner#
Adult/geriatric outpatient approach to headache: screen for secondary red flags (SAH, meningitis, mass, GCA), then treat common primary headaches with clear follow-up and return precautions.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
- Smartphrase snippets
Red flags / send to ED#
- Thunderclap: sudden severe “worst headache,” peak in <1 minute (possible SAH)
- New headache with focal neuro deficit, altered mental status, or seizure
- Fever + neck stiffness/photophobia (possible meningitis/encephalitis)
- New headache with papilledema, persistent vomiting, or worse lying down/with Valsalva (possible increased ICP)
- Age >50 with new headache, jaw claudication, vision changes, scalp tenderness (possible GCA)
- Immunosuppression, cancer, or pregnancy/postpartum (out of scope by default) with new severe headache
- New severe headache after head trauma or while anticoagulated (follow local protocol)
- “Worst headache of life” with exertion/sex trigger, collapse, or persistent vomiting (treat as thunderclap until proven otherwise)
Key history#
- Onset: sudden vs gradual; first/worst vs recurrent; change from baseline pattern
- Time course: minutes/hours/days; episodic vs daily; duration of attacks
- Location/quality: unilateral vs bilateral; throbbing vs pressure; “band-like”
- Associated symptoms: nausea/vomiting, photophobia/phonophobia, aura, autonomic symptoms (tearing/congestion), neck pain
- Triggers: missed meals/sleep, dehydration, stress, exertion, alcohol, posture
- Medication use: how often using NSAIDs/acetaminophen/caffeine/triptans (medication-overuse risk)
- Risk factors: vascular risk, cancer, immunosuppression; temporal symptoms (GCA screen)
- Headache “phenotype” questions that change management:
- Migraine: worsened by activity, nausea, photo/phonophobia, prefers dark room
- Cluster: severe unilateral with tearing/congestion, pacing, short attacks, circadian pattern
- Secondary: new pattern in older adult; persistent progressive worsening; positional/Valsalva triggers
Focused exam#
- Vitals (fever, BP), general appearance
- Neuro screen: mental status, speech, pupils, EOM, facial symmetry, limb strength/sensation, gait
- Fundoscopy if feasible (papilledema)
- Meningeal signs when indicated
- Temporal artery tenderness + jaw symptoms when GCA suspected
- Sinus/ENT and neck exam if indicated
- Neck ROM and focal tenderness if cervicogenic pattern suspected (also see Neck pain)
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Migraine | “Throbbing,” “light hurts,” nausea | Episodic; worsened by activity; ±aura | Neuro exam normal | Acute migraine therapy + trigger plan |
| Tension-type headache | “Pressure,” “tight band” | Bilateral; mild–moderate; no nausea | Scalp/neck muscle tenderness | NSAID/acetaminophen + sleep/posture plan |
| Cluster headache | “Stabbing,” “one eye watering,” “can’t sit still” | Severe unilateral; autonomic symptoms; short attacks | Neuro exam normal | Same-week evaluation; treat and counsel |
| Cervicogenic headache | “Starts in neck,” occipital | Neck pain + motion-related | Reproduces with neck ROM/palpation | Treat neck source; PT |
| Medication-overuse headache | “Daily headache,” frequent meds | ≥15 days/month with frequent analgesic use | Neuro exam normal | Taper overused meds + bridge plan |
| Sinus/ENT-associated headache | “Pressure,” congestion | URI symptoms; worse bending forward | Sinus tenderness (variable) | Treat underlying ENT issue |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Subarachnoid hemorrhage | “Worst headache,” “thunderclap” | Sudden peak <1 min; exertion/sex trigger | Neuro may be normal early | ED now; emergent imaging |
| Meningitis/encephalitis | “Fever,” “stiff neck” | Fever + meningismus/AMS | Neck stiffness; AMS | ED now |
| Giant cell arteritis | “New headache,” jaw pain | Age >50; jaw claudication; vision sx | Temporal tenderness; vision changes | Same-day urgent eval; treat per protocol |
| Mass/increased ICP | “Worse lying down,” vomiting | Progressive, positional, neuro sx | Papilledema or focal deficits | ED/urgent imaging |
Workup#
- No imaging for typical recurrent migraine/tension headache with a normal neuro exam and no red flags.
- If red flags or abnormal neuro exam: ED pathway and imaging per protocol.
- Consider imaging/urgent evaluation for a new cluster-like phenotype in an older patient, atypical features, or abnormal exam.
- For suspected GCA: ESR/CRP and same-day evaluation per local protocol (do not delay if vision symptoms).
- Consider targeted labs only when indicated (e.g., infection concern, metabolic triggers).
- Do not use sinus imaging for uncomplicated “sinus pressure” headaches without concerning features; treat based on the clinical syndrome.
Initial management#
- Treat pain early and adequately; ensure hydration, sleep, and trigger avoidance plan.
- Avoid escalating to opioids; reassess diagnosis if pain is severe and out of proportion.
- If headaches are frequent, address prevention and medication-overuse risk.
- Set a simple “if/then” rescue plan and a follow-up interval so patients don’t keep cycling through urgent care.
Management by diagnosis#
Migraine#
Education:
- Early treatment is more effective; take medication at first sign of headache, not after it’s severe
- Limit rescue meds to ≤10 days/month (triptans) or ≤15 days/month (NSAIDs) to avoid medication-overuse headache
- Identify and avoid triggers (sleep disruption, dehydration, skipped meals, alcohol, stress)
- Consider vestibular migraine if dizziness is a major feature (see Dizziness / vertigo)
Treatment—Acute:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Sumatriptan | 50–100 mg PO; may repeat x1 after 2h (max 200 mg/day) | CAD, uncontrolled HTN, stroke/TIA, hemiplegic migraine, MAOIs | CV symptoms | $ | First-line triptan; also available as nasal spray (20 mg) or injection (6 mg SC). No renal adjustment needed. |
| Rizatriptan | 5–10 mg PO; may repeat after 2h (max 30 mg/day) | Same as sumatriptan; reduce dose with propranolol | CV symptoms | $ | Fast onset; 5 mg if on propranolol |
| Naproxen | 500–750 mg PO at onset | GI bleed, CKD (avoid if eGFR <30), CV disease | Cr if frequent use | $ | Good first-line; can combine with triptan |
| Ibuprofen | 400–800 mg PO at onset | Same as naproxen | Same | $ | Alternative NSAID; avoid in CKD |
| Metoclopramide | 10 mg PO/IV with analgesic | Parkinson’s, tardive dyskinesia | EPS with repeated use | $ | Antiemetic + enhances analgesic absorption |
| Acetaminophen + caffeine | 1000 mg + 130 mg (e.g., Excedrin) | Liver disease; limit caffeine if frequent | Caffeine overuse | $ | OTC option; watch for medication-overuse; safe in CKD |
Menstrual migraine: if predictable, consider scheduled NSAID or triptan starting 2 days before expected menses through day 3.
Treatment—Preventive (consider if ≥4 headache days/month or significant disability):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Propranolol | 40–160 mg/day (start 20 mg BID) | Asthma, bradycardia, decompensated HF | HR, BP | $ | First-line; also helps anxiety; avoid abrupt discontinuation. Good in elderly if no bradycardia. |
| Topiramate | 25–100 mg/day (start 25 mg QHS, titrate weekly) | Kidney stones, glaucoma, pregnancy | Cognitive SE, weight, bicarb | $ | Weight loss effect; teratogenic—requires contraception. Avoid in elderly (cognitive SE). |
| Amitriptyline | 10–50 mg QHS (start 10 mg) | Glaucoma, urinary retention, cardiac conduction disease | Anticholinergic SE; ECG if cardiac hx | $ | Good if insomnia or tension-type overlap. Caution elderly (anticholinergic, falls). Start 10 mg in elderly. |
| Venlafaxine | 75–150 mg/day | Uncontrolled HTN, MAOIs | BP | $ | Alternative if depression/anxiety comorbid |
| Magnesium oxide | 400–500 mg daily | Renal impairment (avoid if eGFR <30) | Diarrhea | $ | Low risk; modest evidence; good adjunct. Reduce dose in CKD. |
| Riboflavin (B2) | 400 mg daily | None | None | $ | Takes 3 months for effect; very safe; good option in elderly/CKD |
Elderly patients: prefer propranolol (if no bradycardia), magnesium, or riboflavin. Avoid topiramate (cognitive) and use low-dose TCAs cautiously (anticholinergic burden, falls).
CGRP inhibitors (erenumab, fremanezumab, galcanezumab): specialist-initiated; consider referral if 2+ preventives fail.
Follow-up: 4–6 weeks to assess acute therapy; 8–12 weeks to assess preventive efficacy. Earlier if new neuro symptoms, change in pattern, or poor control.
Tension-type headache#
Education:
- Often linked to sleep deprivation, stress, poor posture, or eye strain
- Headaches should gradually improve with lifestyle changes
- Frequent analgesic use can paradoxically worsen headaches
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Ibuprofen | 400–600 mg PRN (max 2400 mg/day) | GI bleed, CKD, CV disease | Cr if frequent | $ | First-line; limit to ≤15 days/month |
| Acetaminophen | 650–1000 mg PRN (max 3 g/day) | Liver disease, alcohol use | LFTs if prolonged | $ | Alternative if NSAIDs contraindicated |
| Naproxen | 250–500 mg BID PRN | Same as ibuprofen | Same | $ | Longer duration of action |
Preventive (if ≥15 days/month or chronic):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Amitriptyline | 10–50 mg QHS | Glaucoma, urinary retention, cardiac disease | Anticholinergic SE | $ | First-line preventive; helps sleep |
| Nortriptyline | 10–50 mg QHS | Same as amitriptyline | Same | $ | Less sedating than amitriptyline |
Follow-up: 4–6 weeks if persistent or frequent; address sleep, stress, ergonomics.
Cluster headache (suspected)#
Education:
- Severe unilateral headaches with autonomic symptoms (tearing, nasal congestion, ptosis) lasting 15–180 minutes
- Attacks often occur at same time daily, frequently at night; cluster periods last weeks to months
- Time-sensitive treatment can abort attacks; preventive therapy shortens cluster periods
Treatment—Acute (abortive):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| High-flow O2 | 12–15 L/min via non-rebreather x 15–20 min | None | None | $$ | First-line; 70% effective; requires Rx for home O2 |
| Sumatriptan SC | 6 mg SC; may repeat x1 after 1h | CAD, uncontrolled HTN, stroke | CV symptoms | $$ | Fastest triptan onset; preferred over oral |
| Sumatriptan nasal | 20 mg; may repeat after 2h | Same as SC | Same | $ | Alternative if injection refused |
| Zolmitriptan nasal | 5 mg; may repeat after 2h | Same | Same | $$ | Alternative nasal triptan |
Treatment—Preventive (bridge/transitional):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Verapamil | 240–480 mg/day in divided doses (start 80 mg TID) | Heart block, severe HF, concurrent beta-blocker | ECG at baseline and with dose increases | $ | First-line preventive; may need high doses |
| Prednisone | 60–80 mg/day x 5 days, then taper over 2–3 weeks | Active infection, uncontrolled DM | Glucose, mood | $ | Bridge therapy while verapamil titrated |
Neurology referral recommended for all suspected cluster headache; specialist may add lithium, topiramate, or occipital nerve block.
Follow-up: within 1 week; urgent neurology referral.
Medication-overuse headache#
Education:
- Frequent rescue meds (≥10–15 days/month) can perpetuate daily headaches
- Withdrawal may temporarily worsen headaches for 1–2 weeks before improvement
- Prevention is key: limit acute meds and optimize preventive therapy
Treatment:
- Structured taper of overused medication over 2–4 weeks
- Bridge therapy during withdrawal:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Naproxen (scheduled) | 500 mg BID x 2–4 weeks | GI bleed, CKD, CV disease | GI symptoms | $ | Bridge if overusing triptans or combination analgesics |
| Prednisone | 60 mg x 5 days, taper over 1 week | Active infection, uncontrolled DM | Glucose | $ | Short bridge for severe withdrawal |
- Start or optimize preventive therapy (see Migraine preventives above)
- Consider neurology referral if multiple failed attempts
Follow-up: 2–4 weeks during taper; close support improves success.
Cervicogenic headache#
- Education: treating the neck source improves headaches.
- Treatment: PT/manual therapy as appropriate, ergonomics, sleep positioning; analgesics/topicals as needed; coordinate with Neck pain.
- Follow-up: 4–6 weeks.
Suspected GCA (age >50 + compatible symptoms)#
Education:
- Vision loss risk makes this time-sensitive; permanent blindness can occur within hours to days
- Treatment should not be delayed for biopsy results
Treatment:
- If vision symptoms present: start prednisone 60 mg daily immediately and arrange same-day ophthalmology/rheumatology evaluation
- If no vision symptoms: start prednisone 40–60 mg daily and arrange urgent evaluation within 24–48 hours
- Order ESR and CRP (both elevated supports diagnosis; normal does not exclude)
- Temporal artery biopsy should be arranged but does not delay treatment
Follow-up: urgent same-day if vision symptoms; within 24–48 hours otherwise. Rheumatology to manage long-term.
Follow-up#
- Reassess in 2–4 weeks if headaches are frequent, worsening, or require a prevention plan.
- Reassess in 4–6 weeks for typical migraine/tension once a plan is started.
- Escalate urgently for thunderclap onset, fever/neck stiffness, new neuro deficits, vision changes, or rapidly worsening pattern.
- If not improving after 4–6 weeks (or increasing frequency), escalate (optimize prevention, address medication-overuse, and reconsider secondary causes/imaging thresholds).
Patient instructions#
- Treat early at the start of a headache and stay hydrated; prioritize sleep and regular meals.
- Limit rescue medication use to avoid rebound headaches (follow the plan you were given).
- Avoid opioids for headaches unless specifically directed by your clinician.
- Track frequency/triggers and bring the log to follow-up.
- Seek urgent care now for a sudden “worst headache,” fever with stiff neck, new weakness/numbness, confusion, or vision changes.
Smartphrase snippets#
Migraine, acute visit:
Episodic headache consistent with migraine: unilateral, throbbing, with photophobia and nausea. No red flags (no thunderclap onset, no fever, no focal deficits, no papilledema). Neuro exam normal. Discussed trigger avoidance and early treatment. Prescribed [triptan/NSAID]. Return precautions reviewed.
Tension-type headache:
Bilateral pressure-type headache without nausea or photophobia, consistent with tension-type headache. No red flags. Neuro exam normal. Discussed sleep hygiene, stress management, and posture. PRN analgesics with limit of <15 days/month to avoid medication-overuse. Follow up if worsening or not improving in 4–6 weeks.
Headache with red flag workup:
New headache with [concerning feature]. Given red flag, referred to ED for [imaging/LP/urgent evaluation]. Discussed with patient the need to rule out [SAH/meningitis/mass/GCA]. Patient instructed to go directly to ED.
Related pages#
Complaint pages#
- Dizziness/Vertigo — vestibular migraine overlap, dizziness as migraine feature
- Neck pain — cervicogenic headache evaluation and management
- Syncope — if headache with loss of consciousness
- Depression — chronic headache and mood comorbidity
Problem pages#
- Migraine — comprehensive ongoing migraine management
- Peripheral Neuropathy — if numbness/tingling accompanies headache (rare)