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Kaniecki R. Headache Assessment and Management. JAMA. 2003;289(11):1430–1433. doi:10.1001/jama.289.11.1430
Author Affiliation: The Headache Center, Department of Neurology, University of Pittsburgh, Pittsburgh, Pa.
Contempo Updates Section Editor: Sarah Pressman
Lovinger, MD, Fishbein Fellow.
The lifetime prevalence of headache is more than 90%.1 In
recent population-based surveys of US adults, nearly 25% annually report recurrent
episodes of severe headache and 4% daily or near-daily headache.2-4 Prescription
or nonprescription products are used by 9% of US adults each week to treat
headache, matching hypertension as the primary reason for medication use.5 The majority of patients presenting to physicians
will have primary headache syndromes such as tension-type, cluster, and migraine.
Less than 2% of patients in office and 4% of patients in emergency department
settings will be found to have headaches secondary to significant pathology.6
Recurrent headaches provoke consultation when they are debilitating,
frequent, or associated with worrisome neurological or systemic symptoms.
Episodic tension-type headache annually affects 38% of US adults, yet rarely
requires medical attention given the typical absence of disability or concerning
symptoms.7,8 Cluster headache
generally leads to significant disability and assorted autonomic features,
but it is uncommon in office practice due to low population prevalence (<0.1%).9 Migraine headache is disproportionately represented
in office settings because of its high prevalence, significant disability,
and strong association with neurological and gastrointestinal symptoms. A
recent investigation has shown that more than 90% of initial headache consultations
in a primary care office setting will involve patients experiencing attacks
meeting International Headache Society (IHS) criteria for migraine, although
only 3% experience solely episodic tension-type headache.10
Migraine, affecting 18% of women and 6% of men in the United States,
remains underdiagnosed and undertreated. A recent population-based survey
determined that fewer than half of those experiencing headaches meeting criteria
for migraine have been diagnosed.2 Insufficient
clinical training may be a factor, because only 48% of internal medicine and
62% of family practice residency graduates report being very prepared to treat
patients with headache.11 It is thus not surprising
that the majority of undiagnosed migraineurs are actually given alternative
diagnoses, with 42% labeled as sinus headache and 32% labeled as tension headache.2 The most important variable in misdiagnosis is in
fact the self-diagnosis provided by the patient. A critical reappraisal of
the methods of identifying migraine in the outpatient population is clearly
Headache may arise from conditions that range from benign to catastrophic.
The initial step in headache assessment requires screening for secondary origins.
A thorough history combined with general and focused neurological examinations
are mandatory. Neuroimaging procedures or analysis of serum or cerebrospinal
fluid is required when one of the red flags of secondary headache presentations
(Box 1).12 The available data
are insufficient to recommend either computed tomography or magnetic resonance
imaging as a more sensitive modality. The routine use of electroencephalography
in the evaluation of headache patients is no longer warranted.13
Fundamental change or progression in headache pattern
First and/or worst headache
Abrupt-onset attacks, including those awakening one from sleep
Abnormal physical examination results (general or neurological)
Neurological symptoms lasting >1 hour
New headache in individuals aged <5 years or >50 years
New headache in patients with cancer, immunosuppression, pregnancy
Headache associated with alteration in or loss of consciousness
Headache triggered by exertion, sexual activity, or Valsalva maneuver
Once secondary origins of headache have been excluded, it is next helpful
to divide primary headaches into episodic and chronic headache disorders.
The term chronic is applied by the IHS to those conditions
involving attacks occurring more frequently than 15 days per month for more
than 6 months.14 More than 4% of the US adult
population report chronic daily headache.4 The
majority have chronic forms of either migraine or tension-type headache.4 The pathophysiological basis for the transformation
of episodic tension-type or migraine headache into their more chronic forms
is not well understood. Physical or emotional trauma, major life change, surgery,
and female hormone changes may act as catalysts. Often these patients are
overusing acute headache medications, decongestants, muscle relaxants, sedatives,
or anxiolytics, which may perpetuate the headache disorder. Comorbid depression,
anxiety, insomnia, fibromyalgia, and significant headache-related disability
may all require attention. Due to these factors, chronic daily headache is
therapeutically challenging and the most common consultation in specialty
The majority of patients in primary care settings will experience episodic
primary headache disorders.5,10 Traditional
diagnosis is founded on a symptom-based paradigm initially developed by the
IHS for purposes of clinical research.12 Significant
symptom overlap between the primary headaches has raised concerns regarding
the clinical specificity of such a system.
Tension-type headache is the least distinct of the primary syndromes,
defined by the absence of associated features.5 The
pain is mild or moderate in intensity, generally bilateral, and nonpulsatile.
It typically remains unchanged or improves with physical activity. Stress
is listed as the most common trigger. Due to its limited disability, episodic
tension-type headache rarely is the basis for consultation in primary care
or specialty settings.
Episodic cluster headache is distinguished by its distinctive temporal
pattern of grouped headache attacks recurring over several weeks or months.7 The episodes are characterized by minutes-to-hours
of intense unilateral periorbital pain associated with nasal or ocular autonomic
features. Due to its low population prevalence, cluster headache is also an
infrequent consultation in primary care.
Given the significant underdiagnosis of migraine, the clinical applicability
of a symptom-based diagnostic system has been called into question.15 The characteristics of migraine attacks vary both
among patients and among episodes within a single patient. Although the pain
of migraine is typically considered to be unilateral and throbbing, 40% of
migraineurs may present with bilateral pain and half with nonpulsatile pain.
Recent data have shown that 46% of migraineurs in a headache clinic setting
describe cranial autonomic features, such as tearing or nasal congestion,
symptoms often assigned to sinus headache.16 New
research on patients with recurrent sinus headache in a primary care setting
has shown that approximately 90% will experience attacks meeting IHS diagnostic
criteria for migraine.17 Another study has
shown that 75% of migraineurs report neck pain with their attacks, a feature
thought to be more typical of tension headache.18 The
inherent variability of migraine pain (location, description), triggers (barometric
pressure changes, stress), and associated features (autonomic symptoms, neck
pain) may help explain the underdiagnosis and misdiagnosis of migraine when
the model for headache diagnosis is symptom-based.
As a result of the deficiencies of such a model, alternative migraine
recognition instruments have been proposed, with varying degrees of validation.15 Pattern-based and impact-based recognition models
are appealing because episodic disabling headache in the absence of red flags,
daily headache, and analgesic overuse is almost invariably migraine. An instrument
known as the Brief Headache Screen has been validated in a primary care setting
as correlating well with IHS criteria for migraine and a modified 4-question
version has been adopted by the American Academy of Neurology19,20:
(1) How often do you get severe headaches? (2) How often do you get other
(milder) headaches? (3) How often do you take headache relievers or pain pills?
and (4) Has there been any change in your headaches over the past 6 months?
Secondary headaches are managed through treatment of the underlying
pathology. Because a variety of headaches have been shown to improve following
triptan delivery, response to treatment should not be used as a diagnostic
tool for migraine or other primary headache conditions.21
Tension-type headache may be addressed with nonpharmacological strategies
such as relaxation training, stress management, and counseling.7 When
frequent, a trial of a tricyclic or a newer antidepressant are warranted.
No comparative data are available to recommend any specific agent. Acute attacks
may be managed with simple or combination analgesics, limited to 2 to 3 days
per week to avoid medication-overuse headache. There is no evidence that muscle
relaxants are effective in the treatment of episodic tension-type headache.
In patients with chronic tension-type headache, a combination of amitriptyline
hydrochloride and stress management proved more effective than either therapy
Cluster headaches are often managed with short-term preventive agents
such as corticosteroids or ergotamine tartrate during the initial 2 to 4 weeks.9 Long cluster episodes may require months of verapamil,
methysergide, or lithium carbonate. First-line treatment of acute cluster
headache is oxygen delivered at 7 to 12 L/min for 15 minutes. The only highly
effective abortive agent is subcutaneous sumatriptan, with parenteral dihydroergotamine,
intranasal sumatriptan, and intranasal lidocaine as alternatives.
Evidence-based guidelines are now available for the nonpharmacological
and pharmacological management of migraine headaches. Following a comprehensive
review of all placebo-controlled trials, the US Headache Consortium published
evidence-based guidelines for acute and preventive therapies of migraine in
a primary care setting.23 Clinical guidelines
based on these publications have been adopted by the American Academy of Family
Physicians and the American College of Physicians–American Society of
Internal Medicine (Box 2).24
Use nonsteroidal anti-inflammatory drugs as first-line therapy:Aspirin (325-975 mg/dose by mouth)Ibuprofen (400-800 mg/dose by mouth)Naproxen
sodium (375-550 mg/dose by mouth)Tolfenamic Acid (200-400 mg/dose by mouth)†Combination
of acetaminophen + aspirin + caffeine (2 tablets per dose by mouth)
Use migraine-specific agents in nonsteroidal anti-inflammatory drug
failures:Dihydroergotamine (0.5-1 mg/dose intranasal)Naratriptan
(1-2.5 mg/dose by mouth)Sumatriptan (50-100 mg/dose by mouth,
6 mg/dose subcutaneous)Rizatriptan (5-10 mg/dose by mouth)Zolmitriptan (2.5-5 mg/dose
Select nonoral route of administration for those with early or significant
nausea or vomiting
Recommended first-line agents:Amitriptyline (25-150 mg/d)Divalproex
sodium (500-1500 mg/d)Propranolol (80-240 mg/d)Timolol (20-30 mg/d)Sodium
valproate (800-1500 mg/d)
*Adapted with permission from Snow et al.24†Not available in the United States.
The design of an effective treatment program begins with profiling both
the headache condition and patient variables. Those patients with frequent
or extremely debilitating attacks are candidates for prevention. Those patients
with rapidly developing pain, migraine upon awakening, or prominent gastrointestinal
symptoms may warrant nonoral routes of acute drug administration. Important
patient variables include age, sex, child-bearing status, and medical conditions
such as hypertension and vascular disease. Depression, anxiety disorders,
irritable bowel syndrome, and epilepsy are comorbidities of migraine, which
should be considered in the design of a treatment program.
Evidence-based guidelines support the efficacy and tolerability of nonsteroidal
anti-inflammatory drugs as first-line therapies for acute attacks. Patients
who cannot tolerate nonsteroidal anti-inflammatory drugs or those who fail
to achieve complete pain freedom in 2 hours are candidates for migraine-specific
therapies. Serotonin 1B/1D agonists (triptans) and dihydroergotamine are the
most effective agents in this category. Contraindications to migraine-specific
drugs include significant vascular or cardiac disease, uncontrolled hypertension,
and the uncommon hemiplegic and basilar migraine variants. There is no evidence
to support the use of acetaminophen or butalbital compounds in migraine, and
little evidence to support the use of isometheptene compounds. Opioids should
be reserved for those situations in which other acute therapies have failed
or are contraindicated.
There are several strategies for the acute management of migraine. A
model based on stratified care (treatment intensity matched to headache disability)
demonstrates superiority over models based on step care (agent selection based
on cost) or staged care (milder first-line and stronger second-line agents).25 No data are available to analyze specific treatment
schedules, but experts recommend limiting acute therapies to 2 days per week
to avoid medication-overuse headache. The goals of acute therapy are to treat
attacks rapidly, effectively, and consistently to reverse or prevent disability,
minimize requirements for rescue medication, and optimize self-care. A growing
body of evidence supports the early treatment of acute migraine headache while
it remains in the mild phase.26 Such an approach
maximizes pain-free efficacy and minimizes adverse events and headache recurrence.
Triptan treatment while migraine pain remains mild also results in substantially
decreased total costs per treated attack.27 Because
the majority of migraineurs do not experience consistent complete relief with
any individual treatment, a program providing 2 possible treatments may be
both valuable and preferred over those regimens providing a single option
for acute attacks.28
Nonpharmacological strategies can be used alone or in combination with
pharmacological therapies in the stabilization and prevention of migraine.
Evidence is available to support recommendations for relaxation training,
thermal or electromyogram biofeedback, and cognitive-behavioral therapy.23 Small studies support modest efficacy of magnesium,
riboflavin, and feverfew.23 Regulation of sleep,
meals, and exercise patterns; reductions of dietary and pharmacological stimulants;
and trigger avoidance are also helpful nonpharmacological recommendations.
Pharmacological migraine-preventive agents are indicated in situations
of headache frequency more than twice per week; contraindication to, failure
of, or adverse effects from acute therapies; significant headache disability
despite acute therapies; presence of unusual migraine syndromes (hemiplegic,
basilar, prolonged aura, migrainous infarction); and patient preference. Goals
of preventive therapy include reduction of attack frequency, severity, and
duration. Improved responsiveness to acute treatments may also occur. Complete
headache elimination is rarely achieved. Recommended first-line agents for
the prevention of migraine headache include certain β-blockers, tricyclic
antidepressants, and anticonvulsants (Box 2). Clinical benefit may require
2 months to manifest and consideration should be given to tapering the drug
following a 6-month period of relative stability. The overuse of acute medications
(>2 days per week) must be avoided to ensure optimal effectiveness of preventive
Consensus exists regarding the importance of patient education in migraine.24 Physicians should review the biological basis and
genetic underpinnings of the sensitive nervous system responsible for migraine.
A discussion of the risks, benefits, and realistic expectations from acute
and preventive medications is imperative. Encouraging active participation
in care through lifestyle suggestions and headache calendar completion is
useful. Diaries documenting headache events, triggers, and response to treatments
are indispensable in monitoring progress on a regular basis. Successful outcomes
often arise from a vigorous therapeutic partnership between patient and physician.
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