Primary Care Management of Headache: Part 1

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Headache is the most common neurologic condition that is seen in the primary care setting. The most important initial assessment for the primary care clinician is to distinguish between primary headache versus secondary headache. New-onset headache, new or worrisome neurological signs or symptoms, a strong positional component to the headache, or a pattern of escalation may warrant imaging or referral to a neurologist or headache specialist. In addition, headache needs to be carefully evaluated in patients with cancer, HIV, fever, and in the elderly.

Fortunately, the majority of headache in the primary care setting is a primary headache disorder including tension, migraine, and cluster. Although tension headache is the most common primary headache disorder, it is seen less often than migraine in the primary care setting as by definition, the severity of tension headache is only mild to moderate and is typically not associated with nausea, vomiting, sensitivity to light, or sensitivity to noise. Tension headache rarely drives an individual to see a clinician.

Cluster headache is very rare and uncommonly seen in primary care offices. Referred to as the “suicide” headache, the severity often drives the individual to an emergency department. Unlike an individual with migraine, a patient with cluster presents with a severe, boring, piercing pain behind one eye with associated autonomic symptoms including tearing and nasal congestion on the affected side. The patient with cluster headache will typically be agitated and pacing when they present in the primary care setting. It is more common in men, is often familial, and is aggravated by alcohol. The term “cluster” refers to the most common type of the headache; episodic cluster is used when the individual has his/her headaches “clustered” together for example in a 6-12-week time frame followed by months of being headache free. If a cluster headache is suspected, referral to a neurologist or headache specialist is advisable to confirm the diagnosis.

Migraine is the most common primary headache seen in the primary care setting. The majority of patients with migraine can be appropriately managed by his/her primary care clinician. If a patient presents with a 6-month or greater pattern of a disabling headache, then most likely the diagnosis is migraine. Associated symptoms to ask about to help confirm the diagnosis include nausea, vomiting, sensitivity to light, sound, and/or smell. Unlike the agitation and pacing of a patient having a cluster headache, the patient with migraine wants to lie down in a dark, quiet room. Often, they would like to “sleep it off.” If unsuccessfully treated, a migraine attack can last up to 72 hours. There is often family history of migraine, and the headache is more common in women. Triggers include stress, hormonal fluctuations, changes in barometric pressure, and dietary triggers such as preservatives, artificial sweeteners, and tyramine. Most patients can identify at least some of their triggers. Keeping a headache diary can help with pattern recognition and identification of triggers.

Once diagnosed, migraine treatment includes acute and preventive treatment. The goal for acute treatment of a migraine attack is to be headache- free and back to full function within 2 hours. Some individuals can achieve this goal with over-the-counter analgesics including a popular combination containing aspirin, acetaminophen, and caffeine. Others may need a prescription for an abortive medication with options such as a prescription-strength NSAID, triptans, ergotamines, gepants, or a ditan. The most cost effective would be a generic triptan. Triptans are available in oral, orally disintegrating, intranasal, and injectable formulations. Sumatriptan offers the advantage of oral, intranasal, and injectable formulations. Importantly, some patients may need a non-oral delivery method for treatment of migraine attacks that are more severe and/or associated with nausea/vomiting.

Gepants include ubrogepant and rimegepant. They are oral calcitonin gene-related peptide (CGRP) receptor antagonists. Features of this class include no vasoconstriction, no evidence of medication overuse, and a favorable tolerability profile. Gepants can be a good acute treatment option if an individual cannot tolerate the triptans or has a contraindication to taking a triptan. Triptans are vasoconstrictive and should be avoided in those with uncontrolled hypertension, coronary artery disease, peripheral vascular disease, or those with several cardiovascular risk factors. In addition, triptan dosing should be ideally limited to a maximum of 3 times per week to avoid medication overuse and its sequelae-medication overuse headache (MOH).

As of 2023, there is only one agent in the ditan class, called lasmiditan. It is a 5HT-1F receptor agonist. It crosses the blood brain barrier and is associated with dizziness and sedation. Driving is restricted for 8 hours after taking the medication. If a patient is willing to comply with the driving restriction and would not mind “sleeping off” a severe migraine, then prescribing this ditan may be an option. At this time, it is not known if ditans can lead to MOH.

Butalbital, a barbiturate, and opioids should not be used for the acute treatment of migraine attacks. Drugs in these categories are not migraine-specific and can often lead to medication overuse/MOH and addiction.

Primary care clinicians should be comfortable prescribing all the above-named acute treatments for migraine in their practice. If a patient is not finding relief from several different acute treatments, then reconsideration of the diagnosis of migraine is warranted. If the diagnosis is unclear, then referral to a neurologist or headache specialist is advisable. Once diagnosed and with an effective treatment plan, the patient could potentially be referred to the primary care clinician for ongoing management.