Headache Diagnosis and Management

• Immediate emergency department referral should be given to patients who have abrupt-onset "thunderclap headache," head injury, or headache with associated neurologic abnormalities including change in mental status.
• 90% to 95% of the population experiences headaches.
• Headache is the 3rd most common health complaint and cause of disability in the world.
• Many people with headache are never diagnosed by a physician.
• Many patients with headaches use over-the-counter (OTC) medications and other home remedies and do not seek care for their headaches because they do not believe satisfactory treatment is available.
• One must differentiate secondary from primary headaches because secondary headaches can be harbingers of a potentially more serious medical condition than the benign, primary headaches
• Secondary headaches are less common and are usually the result of an underlying disease or condition, such as aneurysm, tumor, hemorrhage, temporal arteritis, or meningitis.
• Once the primary condition has been identified and treated, secondary headaches may dissipate.
• Primary headaches are more common and are not symptomatic of another medical condition.
• Types of primary headaches include migraine with and without aura, chronic or episodic tension-type headache, trigeminal autonomic cephalalgias (TAC), and other primary headache disorders, such as medication overuse or rebound headache.
• Primary headache disorders affect people of all ages, races, income levels, and geographic areas.
• Primary headache disorders have an estimated lifetime prevalence of 47% in adults worldwide.
• These headaches may range in intensity from mild to severe and can cause considerable distress, disability, expense, and loss of work time.
• Headaches account for up to 4% of all emergency department visits and are one of the most common reasons to consult a health care provider.
• Tension-type headaches have a lifetime prevalence of up to 78% in the general population and are a significant risk for opioid overuse.
• Clinical and research evidence has demonstrated a relationship between migraine and other disease processes, including epilepsy, major depression or panic disorder, celiac disease, Raynaud syndrome, and cardiac shunting.
• The neurotransmitter serotonin has been suggested as a basis for both migraine and major depression.
• Knowing a co-occurrence may exist can aid in the treatment of each disease and provides clues to the pathophysiologic mechanism of migraine and other headache disorders.

Pathophysiology

• The exact mechanism of a headache is debated.
• There is a genetic component, and there is often a family history of migraine.
• Headaches were previously thought to be caused by increased blood flow to the head, resulting in distended vessels and pressure on the nerve fibers of the brain. Harold Wolfe determined that migraine was caused by both vascular and chemical changes within the brain.
• Serotonin (5-hydroxytryptamine [5-HT]), a powerful vasoconstrictor, sensitizes the blood vessel walls to painful dilation.
• Other neurochemicals, such as dopamine, substance P (a polypeptide), and calcitonin gene–related peptide (CGRP), may alter the excitability of the brain and mediate the vasoconstriction or vasodilation of blood vessels.
• Neurogenic inflammation is responsible for the pain of migraine.
• During a headache, changes occur in the vasculature of the brain and in the neurochemicals found within the body.
• These changes are a result of a brain response to a stimulus, or trigger.
• Vasodilation and vasoconstriction subsequently cause the release of neurochemicals, which may be responsible for the headache and for the feelings of impending doom or fatigue that can occur before and after an attack.

Clinical Presentation and Physical Examination

• The International Headache Society has developed criteria for various types of headache disorders.
• The criteria can be lengthy and may not be applicable in many primary care settings, but the information does allow the provider to quickly differentiate the various types of primary headache conditions.
• The two major types of migraine are migraine with aura and migraine without aura.
• Migraine without aura is the more common of the two.
• The patient usually experiences an ipsilateral headache with migraines.
• The pain is described as pounding or throbbing, is moderate to severe in intensity, and is aggravated by physical activity.
• Migraines can be chronic or episodic, lasts 4 to 72 hours and may be associated with nausea, vomiting, photophobia, and phonophobia.
• Patients usually retreat to a dark, quiet room until the attack is over.
• They often can identify a trigger that will precipitate the attacks.
• Triggers are an individual characteristic and may be difficult to identify because they may not always stimulate a headache.
• Common triggers include OTC medication overuse, depression, stressful life events, sleep problems including snoring, weather changes (especially low barometric pressure), foods (cheese, chocolate), alcohol use, change in altitude, delay or skipping of a meal, and hormonal changes.
• In migraine with aura, the aura usually occurs before the onset of head pain, although it can sometimes extend into the period of headache.
• The classic aura, or “fortification spectrum,” occurs in about 10% of patients and is described as jagged lines similar to the stone fortifications found around a fort.
• Visual auras can also be characterized by spots, shimmering or flickering bright lights, or areas of visual loss (scotomas).
• Somatosensory-type auras can also occur, with tingling or numbness of the fingers, motor disturbances such as hemiparesis or monoparesis, and cognitive disorders.
• Per the migraine aura criteria, these visual and somatosensory disturbances last at least 5 minutes but less than 60 minutes.
• The patient then experiences head pain and features similar to those of migraine without aura.
• A prodrome can be part of a migraine
• Several days before the aura or start of the head pain, the person may have feelings of doom or fatigue.
• During this period, increased irritability, decreased energy, and food cravings are common symptoms.
• Prodrome can be an early signal that a severe headache is forthcoming and may enable the patient to use both pharmacologic and nonpharmacologic modalities in the hope of aborting the attack.
• Acute tension-type headaches are described as feeling like there is a tight band around the head.
• Criteria allow for photo- or phonophobia but not nausea or vomiting.
• Headache pain is mild (not moderate to severe) and is not exacerbated by activity.
• This headache can last minutes to hours.
• It usually is not exacerbated by physical activity, although a common trigger is stress.
• Overall, the acute tension-type headache is a nagging headache that occurs fewer than 15 days per month, is present most of the day, and may start after the person wakes up.
• It rarely awakens the person.
• Chronic tension-type headache is similar in presentation to the acute type but occurs more often than 15 days per month.
• TAC is the name given to a group of headache syndromes that are differentiated by duration and frequency but all have unilateral autonomic symptoms.
• Cluster headaches fall under this category and are the most well-known.
• The patient with cluster headache, acute or chronic, is usually awakened during the night with severe unilateral, retro-orbital pain.
• A cluster headache reaches maximum intensity in about 15 minutes and usually lasts about 90 minutes, although some can last 3 hours.
• These attacks can occur several times per day.
• The pain is described as agonizing, and unlike migraineurs, these patients often cannot sit still.
• The severe intensity of cluster pain causes restlessness, moaning, crying, and often pacing.
• Patients may indulge in self-hurting behavior and may have thoughts of suicide.
• Other features of cluster headache include ipsilateral injection of the conjunctiva, lacrimation, rhinorrhea, and partial Horner sign.
• For the patient with acute cluster headache, attacks occur in groups (or clusters) lasting days to weeks and then subside until the next attack.
• Years can pass between attacks, and the event often occurs at the same time each year.
• The patient with chronic cluster headache has the same presentation as the patient with the acute type but does not experience any remission longer than 1 month for at least 1 year.
• These headaches are also relatively resistant to therapy.
• Although it is well tolerated between attacks, alcohol use will often precipitate an attack in patients with acute or chronic cluster headache.
• The history is the most important part of the evaluation.
• The diagnosis can be made on the basis of history alone for most primary headache disorders.
• It is important that the patient characterize the headache by describing the duration, quality, and location of the pain.
• The presence or absence of any precipitating factors, or triggers, and the age at onset should be established.
• The presence of associated symptoms, such as nausea, vomiting, and photophobia, should be explored.
• Find out of the patient can be active during these headaches, or does the patient need to lie still in a dark room.
• Find out how the patient describe their sleep and energy, and consider that Sleep is usually labile in the person with headache, and energy may be poor.
• A medication profile is essential and should include medications that have been tried in the past for headache control.
• If OTC medications are taken, the number used per month should be identified because patients may not view OTC drugs as medications.
• Migraine is known to be familial; therefore, it is important to determine whether any family member has had headaches that might have been called sinus headaches or sick headaches or headaches that were disabling.
• Asking about the presence of any physical abuse is important because it has been shown that a history of abuse contributes to refractory headaches.
• A targeted physical examination is important in ruling out harmful secondary headache pathologies and confirms any information given in the history.
• The examination findings in primary headache disorders are usually within normal limits.
• Key aspects of the physical examination include a cardiopulmonary and complete neurologic assessment with a major focus on the following:
  • Fundoscopic and pupillary assessment
  • Auscultation of the carotid and vertebral arteries
  • Mental status examination
  • Palpation of the head, neck, and temporal arteries
  • Evaluation for any neck stiffness, focal weakness, sensory loss, and gait Vital signs
• Many patients with tension-type headaches or migraines have tight cervical musculature.
• Painful biceps insertions, along with general aches and pains along the back, hips, and knees, similar to the pain associated with fibromyalgia, a condition commonly seen in migraineurs.
• Pain and pressure on palpation of the sinuses accompanied by purulent nasal discharge may be indicative of sinusitis.
• The temporomandibular joints may click and pop when the mouth is opened and closed, but rarely is this the cause of a headache.
• Tension is often exhibited in the musculature surrounding this joint, and the subsequent bruxism may potentiate pain in this area.
• Serious symptoms and findings include a headache accompanied by a stiff neck; fever; malaise; nausea or vomiting; and the presence of any aphasia, weakness, or poor coordination.
• The mnemonic SNOOP has been developed to help providers identify dangerous underlying conditions:
  • Systemic symptoms—fever, chills, weight loss, HIV infection, history of cancer;
  • Neurologic signs or symptoms—confusion, change in mental status, seizure, asymmetrical reflexes;
  • Onset—acute, sudden, or split second;
  • Older patient—greater than or equal to 50 years old with new-onset or progressive headache;
  • Previous headache history—first headache or different (change in frequency, severity, features).
• Other danger signs include the following:
  • Asymmetry of pupillary responses
  • Decreased deep tendon reflexes
  • Headache described as “the worst ever experienced”
  • Personality change
  • Onset of a headache that progressively worsens
  • Papilledema
  • Painful temporal arteries
• Further investigation and referral to a specialist or hospital would be warranted with any of these signs.
• Positive neurologic findings on examination are indicative of a central nervous system disorder and should not be attributed to migraine unless a prior pattern has been documented with serious findings previously excluded.

Diagnostics

• The use of diagnostic studies depends on the results of the history and physical examination.
• Most diagnostic studies in the patient with primary headache are unrevealing.
• If the diagnosis is not clear or the history or physical findings are cause for concern, diagnostic studies should be used to distinguish primary headache from a secondary condition.
• Blood tests are usually not indicated, although exceptions—based on history and physical examination findings—may include a complete blood count (CBC) to exclude anemia or an infectious process, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to help exclude temporal arteritis, and thyroid function tests to identify thyroid dysfunction.
• Practice guidelines developed by the US Headache Consortium advocate three principles for diagnostic testing:
  • testing should be avoided if it will not change the management of the patient’s condition
  • testing is not indicated if the patient is not significantly more likely than the general public to have an abnormality
  • testing may make sense in a patient who is excessively concerned that they have a serious condition that is causing the headaches.
• The American Board of Internal Medicine Foundation and the American Headache Society have created recommendations through the Choosing Wisely Campaign to help guide clinicians in choosing the right imaging when appropriate.

Initial Diagnostics for Headache

• Essential Laboratory: None
• Additional Laboratory:
  • Complete blood count (CBC) and differentiala (if indicated)
  • Erythrocyte sedimentation rate (ESR),a C-reactive protein (CRP) (if indicated)
  • Thyroid function tests (if indicated)
• Essential Imaging: None
• Additional Imaging:
  • Computed tomography (CT) scan, magnetic resonance imaging (MRI) (if indicated)

Differential Diagnosis

• Emergency room evaluation is indicated for patients presenting with headache and neurologic signs or symptoms, systemic symptoms, history of acute (split-second) onset, or age over 50 with new headache.
• The history and physical examination will aid in excluding potential differential diagnoses.
• Priority differentials include:
  • Brain hemorrhage
  • Meningitis
  • Pseudotumor cerebri
  • Temporal arteritis
  • Rheumatologic disorders (e.g., lupus erythematosus, rheumatoid arthritis).
• Headache is a feature of many underlying disease processes, and it can be difficult to decipher a primary headache from a symptom secondary to an underlying disease process.
• Primary headaches include migraines, tension-type headaches, TAC (e.g., cluster headache), and other primary headache disorders (e.g., medication overuse, caffeine withdrawal).
• Infectious or inflammatory causes of headache include fever, meningitis, temporal arteritis, Lyme disease, trigeminal neuralgia, rheumatoid arthritis, systemic lupus erythematosus, and sinusitis.
• Ear, nose, and throat causes can include eye disorders, abscess, or earache.
• Structural causes include tumor, hemorrhage, aneurysm, and subdural hematoma.
• Metabolic causes may include thyroid dysfunction, pheochromocytoma, and sleep apnea.
• Other causes of headache are pseudotumor cerebri and trauma.

Interprofessional Collaborative Management

Nonpharmacologic Management

• Nonpharmacologic measures are used in an attempt to control the headache without medication.
• These methods include behavior modification, biofeedback, acupressure, management of headache triggers, and a wellness program.
• In addition, neuromodulation approaches, including single-pulse transcranial magnetic stimulation, noninvasive vagus nerve stimulation (nVNS), and external trigeminal nerve stimulation, represent licensed, well-tolerated approaches to migraine treatment.
• Behavior modification involves use of several methods, such as relaxation through listening to calming recordings and stress management, as well as modification of daily activities.
• Biofeedback involves the use of instrumentation to bring under voluntary control physiologic processes of which the individual is normally unaware.
• For example, during a migraine attack, vasoconstriction of the periphery causes cold hands, so biofeedback training teaches migraineurs to raise their hand temperature and thereby prevent an attack.
• The area between the thumb and the first finger (or other acupressure areas) can be depressed during a headache to offer some relief.
• It is thought that this pressure causes the release of endogenous endorphins and adrenocorticotropic hormones, which aborts the headache in some people.
• A wellness program consisting of balanced meals, regular exercise, and adequate sleep can also be helpful in controlling headache bouts.
• Overall, nonpharmacologic approaches may help patients avoid triggers that might be initiating headaches.
• Another important nonpharmacologic measure is having the patient keep a headache diary.
• The diary documents the number of headaches, triggers, and treatment successes and failures.
• The patient should keep this record daily because attempting to fill it in before a follow-up appointment may be less accurate.
• It is important for the patient to bring the diary to office visits so information can be shared and the treatment plan adjusted, if necessary.

Pharmacologic Management

• Pharmacologic treatment can be divided into two areas: abortive and preventive.
• Management should match the level of therapy to the intensity of the headache.
• If the attack is severe, early intervention is in the patient’s best interest.
• Providers need to supply education and a range of treatment modalities, allowing the patient to select the most effective treatment.

Preventive Therapy

• Preventive therapy is appropriate for patients if they are unable to deal with their attacks, they experience more than four headaches a month, or the attacks are prolonged and refractory to medicine.
• Preventive therapy is given daily and, if successful, will decrease headache intensity and frequency.
• When choosing preventive treatment, the provider must consider the patient’s history, including any comorbid conditions.
• A connection has been shown between epilepsy and migraine, so anticonvulsants, such as divalproex sodium (Depakote), gabapentin (Neurontin), and topiramate (Topamax), can be used successfully in some patients to control migraine.
• A patient with cold hands, Raynaud phenomenon, or hypertension may do well with calcium channel blockers, such as diltiazem (Cardizem) and amlodipine (Norvasc), which cause vasodilation and decrease blood pressure.
• A β-blocker, such as propranolol (Inderal) or atenolol, may be chosen for the patient with palpitations caused by mitral valve prolapse or panic disorders but should be avoided in persons with asthma.
• If sleep is a problem or if chronic pain persists in the shoulders, a tricyclic antidepressant, such as amitriptyline (Elavil), may facilitate sleep and also decrease the sensation of pain.
• Calcium channel blockers prevent calcium from entering the cells and thus decrease their excitability, which may in turn prevent vascular spasm and headache.
• β-Blockers affect the β1-adrenergic receptors and inhibit the usual adrenergic responses.
• Beyond these mechanisms, it has been theorized that either may influence the serotonergic system within the brain and the vascular system.
• The mechanism of action for both β-blockers and calcium channel blockers, however, is not fully understood.
• Both migraine and tension-type headache may result from an imbalance of neurochemicals.
• Adjustment of these neurochemicals to a more normal level may decrease the number and frequency of headaches.
• The tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), modulate the levels of serotonin in the brain.
• Both the tricyclic antidepressants and the SSRIs have an extensive side-effect profile.
• Weight gain and sexual dysfunction may not be acceptable to patients, although the starting dose for many of the medications can be low.
• The SSRIs are better tolerated, but they might not be as effective as the tricyclic antidepressants for treating headaches.
• Onabotulinumtoxin A treatment is approved by the US Food and Drug Administration (FDA) for the prevention of chronic migraine (≥15 days per month of headache for at least 3 months).
• Injections are given every 3 months in the head, neck, and shoulders.
• Treatments are well tolerated and popular, although evidence for benefit is weak.
• CGRP inhibitors are migraine-specific treatments.
• Safety and efficacy results were consistent, resulting in the approval of erenumab, fremanezumab, and galcanezumab by both the FDA and the European Medicines Agency (EMA) for the preventive treatment of episodic migraine and chronic migraine in adults.
• Eptinezumab received FDA approval in February 2020 and is given intravenously every 3 months.

Abortive Therapy

• Abortive therapy is used to treat the intensity and duration of pain during an attack and to manage associated symptoms, such as nausea and vomiting, and is important to prescribe an adequate amount of medication.
• Patients also need to be instructed to take an appropriate amount initially to abort the headache.
• The appropriate medicine depends on the prior response to treatment, the presence of nausea or vomiting, and the interval between headache onset and peak intensity.
• A patient with a severe migraine or cluster attack that peaks to full intensity within 15 minutes will most likely benefit from parenteral or nasal therapy rather than oral medication.
• For many patients, the pain of the headache is severe, but the associated nausea and vomiting are incapacitating.
• Gastric emptying is slowed during a migraine attack, causing gastric stasis, which can be augmented using Medications such as metoclopramide (Reglan) to enhance gastric motility and decrease nausea.
• Rectal formulations can also be used when abortive therapies are prescribed.
• Many commonly used abortive medications are powerful analgesics.
• When these medications, including acetaminophen (Tylenol), aspirin, and ibuprofen (Advil), are taken frequently, a condition called analgesic rebound can develop in a prone individual.
• More recent studies suggest analgesic rebound is not as serious as originally thought, and frequent use of analgesic medication may be a sign of poorly controlled headaches rather than a cause.
• Patients should be instructed to consult with their providers if abortive use exceeds 2 days per week or more than 8 days per month.
• Simple analgesics, such as acetaminophen and aspirin, can represent first-line treatment in the management of mild to moderate headaches.
• Caffeine combinations (Excedrin, Anacin) can potentiate their absorption and analgesia.
• Nonsteroidal antiinflammatory drugs (NSAIDs) are helpful in treating an acute attack.
• Naproxen sodium (Anaprox DS, Aleve) has a longer half-life and a better safety profile than some of the other NSAIDs.
• The addition of metoclopramide to many of the NSAIDs when nausea is present will facilitate their absorption and potentiate their effect.
• NSAIDs should be used with caution in older adults, as side effects are more common in this age group.
• Ergot derivatives are effective in the treatment of moderate to severe attacks that might not have responded to simple or combination analgesics.
• Two forms are currently in use: ergotamine tartrate (Cafergot) and dihydroergotamine.
• Ergotamine tartrate is available in both rectal and oral forms, but the rectal dose is more potent than the oral preparation.
• Dosage regimens need to be reviewed with the patient and adjusted to achieve pain relief without vomiting.
• Dihydroergotamine is available in an injectable form and as a nasal spray.
• The injectable form (D.H.E. 45) can be given by the parenteral, subcutaneous, or intramuscular route.
• The nasal form (Migranal) is easily administered and much more convenient.
• Because all forms of the ergots can cause nausea and vomiting, premedication with an antiemetic, such as promethazine (Phenergan) or prochlorperazine (Compazine), is necessary.
• Ergot derivatives may have a high potential for overuse and subsequent rebound headaches; patients need to be made aware of the risk for rebound headaches when this medication is prescribed.
• With the triptan development, the use of ergot derivatives is no longer considered first-line therapy, although they are effective.
• Triptans give many patients with migraine and cluster headache relief within a short time from the onset of headache.
• The Triptans target 5-HT receptors in the brain that are believed to generate headache.
• Relief can be almost complete, allowing a return to normal daily activities, with few side effects.
• These medications are arterial constrictors and should be used with caution in the presence of known cardiac disease.
• Many forms of triptans are available: oral, “quick melt,” transnasal, injectable, and a transdermal preparation.
• The brands of each medication have slight differences; if one triptan is ineffective, another may prove to be effective for a patient.
• As with most abortive medications, the goal is to take the dose of medication required to stop the headache before it becomes severe.
• The triptans are effective treatment options for the patient with cluster headache, although overuse may be a concern in patients with chronic cluster headache.
• Patients with cluster headache (TAC) use many of the same medications and treatment regimens as do patients with migraine or tension-type headache, while the key to successful treatment is preventing the attacks.
• Because of the rapid onset of the cluster headache, abortive therapy needs to be in either a parenteral or a nasal form.
• Preventive therapy includes Emgality (galcanezumab), verapamil, and lithium as first-line options.
• Verapamil is usually well tolerated and does not require the close monitoring necessary with lithium.
• Calcium channel blockers may prevent the vasospasm that occurs during a cluster attack by blocking the flow of calcium.
• Lithium, long used for bipolar disorder, also controls cluster headaches.
• Levels should be monitored, and patient education about the signs and symptoms of lithium toxicity is important.
• Therapy should be slowly titrated upward.
• Emgality (galcanezumab) 300 mg once-monthly injections are used to treat cluster headache.
• This CGRP subcutaneous injection is well tolerated and FDA approved, with therapy is continued until the patient is free of any attacks for several weeks.
• Patients are then slowly weaned from the medication or can stop Emgality if they are cluster free for 1 month.
• Oxygen can be effective in as many as 75% of patients with cluster headache and should be delivered at a rate of 10 to 15 L/min through a non-rebreather face mask.
• The oxygen should be inhaled at the start of an attack and should be readily available at all times.
• The abortive management of tension-type headaches involves many of the same medications as for migraine, and the same principles should be applied in choosing treatments for these patients.
• For mild attacks, NSAIDs may be helpful and because there usually is no nausea, antiemetics may not be necessary.
• Muscle relaxants such as metaxalone (Skelaxin) and carisoprodol (Soma), used with caution, have been helpful in aborting mild to moderate attacks.
• Triptan drugs may abort a severe tension attack as well.
• As with migraine, the use of these medications 2 days a week or more should prompt a reevaluation of the headache regime, while stress may be triggering the attack to then include nonpharmacologic measures, including physical therapy techniques.
• Indications for referral to a specialist, a headache clinic, or a neurologist include the following:
  • The headache is not easily controlled by routine headache medicines.
  • Rebound headaches or habituation limits outpatient therapy.
  • Headache is new and progressively worsening.
  • Headache is described as the “worse headache of my life.”
  • Headache is affecting the patient’s quality of life.
  • Headache is accompanied by neurologic symptoms that last longer than 30 minutes or is accompanied by numbness or hemiparesis.
• Hospitalization of the patient with headache may be appropriate in some situations.
• Headaches that are resistant to treatment may be rebound headaches and require intravenous medication to help abort the headache resulting in referral to a headache specialist or neurologist for consultation is then advantageous.
• The US Headache Consortium has developed evidence-based practice guidelines for migraine that cover both nonpharmacologic and pharmacologic modalities, with the goals of reducing the frequency of attacks, improving the response to therapy, and restoring the patient to usual functioning. Control can be achieved after a proper diagnosis is made and proper treatment is prescribed. Currently, no cure exists for primary headaches, although control of headache is possible for most patients.

Life Span Considerations

• As patients age, headaches often decrease and rarely appear after the age of 50 years.
• When an older patient is seen with a history of daily headache, analgesic rebound is often the cause; however, secondary processes need to be excluded.
• Triptans and dihydroergotamine pose a risk to older patients secondary to their vasoconstrictive properties. Headaches in these patients should be treated more conservatively with divalproex sodium, metoclopramide, or intravenous magnesium and at home with naproxen or hydroxyzine.
• During pregnancy, the headache pattern can change and many pregnant persons experience a decrease in headaches during the second and third trimesters, although some see no change in the pattern.
• For the pregnant person, headache control is usually limited to abortive medications only, and preventive therapy should be tapered immediately and may safely use Acetaminophen at doses within normal parameters during pregnancy.

Complications

• Misdiagnosis stands as the most serious complication requiring careful histories and physical examinations for all patients who report headache due to requirement for appropriate and timely referral for patients with positive physical findings.
• Delay in diagnosis and treatment can lead to poor outcomes.
• Literature shows an average delay of 10 years for TAC diagnosis resulting in years of inappropriate and ineffective treatment.
• Other complications of headache include status migrainosus
• Dependency on narcotics, barbiturates, tranquilizers, or other agents
• Side effects of medication
• Inadequate treatment
• Interruption of activities of daily living.

Emerging Management Trends

• Over the years, neurotransmitters or neuromodulators have been considered to be involved in headache, but it has been difficult to pinpoint the exact pathophysiology.
• There is release of calcitonin gene-related peptides (CGRP) into the cranial venous outflow in acute migraine and cluster headache attacks.
• Recent CGRP experiments and clinical translational research have led to the development of anti-migraine therapies that inhibit CGRP action.
• CGRP receptor antagonists, the gepants (Ubrelvy and Nurtec ODT), and monoclonal antibodies toward CGRP and the CGRP receptor are all showing positive relief of acute and chronic migraine and cluster headache with few side effects and no rebound effect.
• The first of these agents, erenumab (Aimovig) and galcanezumab (Emgality) being approved by the FDA in 2018, in addition to Gepants, there is development of a series of fully humanized monoclonal antibodies against CGRP or the CGRP receptor for the prophylactic treatment of chronic migraine (attacks >15 days/month) and for frequent episodic migraine.

Patient and Family Education and Health Promotion

• Knowledge and education are important aspects of patient care for enabling patients and families to make choices and help them regain control over headache pain.
• Open communication and reassurance are required during the initial examination and subsequent treatment because many patients believe that they have a life-threatening condition, yet their physical examination findings are normal and a primary headache disorder is determined.
• Family members should be included in the treatment plan because headache often affects both the patient and the family members.

Explore headache diagnosis, when to refer patients to the emergency department, and the differences between primary and secondary headaches. Recognize the risks associated with frequent tension-type headaches and the link between migraines and other medical conditions.