1. Given a patient with a new-onset headache, differentiate benign from serious pathology through history and physical examination.

  2. Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed):

    1. Do the appropriate work-up (e.g., biopsy, computed tomography [CT], lumbar puncture [LP], erythrocyte sedimentation rate).

    2. Make the diagnosis.

    3. Begin timely appropriate treatment (i.e., treat before a diagnosis of temporal arteritis or meningitis is confirmed).

    4. Do not assume that relief of symptoms with treatment excludes serious pathology.

  3. Given a patient with a history of chronic and/or relapsing headache (e.g., tension, migraine, cluster, narcotic-induced, medication-induced), treat appropriately, and avoid narcotic, barbiturate dependence.

  4. In a patient with a history of suspected subarachnoid bleed and a negative CT scan, do a lumbar puncture.

  5. In a patient suffering from acute migraine headache:

    1. Treat the episode.

    2. Assess the ongoing treatment plan. (referral when necessary, take a stepwise approach).

Red Flags

  • Systemic - fever, weight loss, HTN, myalgias, scalp tenderness

  • Neuro - confusion, decreased LOC, papilledema, visual field defect, CN asymmetry, extremity drift/weakness, reflex asymmetry, seizure

  • Onset - Sudden

  • Older - New onset or progressive >50yo

  • Pattern change/progressive - Different or new

  • Papilledema

  • Postural aggravation

  • Precipitated by valsalva (cough, sneeze)

  • Secondary risk factors- HIV, malignancy, trauma, early morning/nocturnal


  • Primary:

    • Migraine

      • 4-72h (untreated)

      • 2 of unilateral, pulsatile, moderate-severe pain, worse with or avoid routine physical activity

      • 1 of nausea/vomiting, photo/phonophobia

    • Tension

      • 2 of Bilateral, non-pulsating (pressing), mild-moderate intensity, not worse with or avoid routine physical activity

      • No N/V, no more than one of photo/phonophobia

    • Cluster

      • Severe unilateral orbital, supraorbital and/or temporal pain, 15-180mins (untreated)

      • One symptom/sign ipsilateral (Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness, miosis, ptosis)

      • Sense of restlessness or agitation

    • If ≥15d/mo for ≥3mo

      • Chronic migraine

      • Chronic tension

      • Medication overuse headache (usually present on wakening)

        • ≥15d/mo simple analgesics (acetaminophen, aspirin, NSAID)

        • ≥10d/mo ergotamine, triptan, opioids

      • Hemicrania continua

        • Strictly unilateral, persistent with exacerbations, cranial autonomic symptoms, restlessness, responsive to indomethacin

      • New daily persistent headache

        • Abrupt onset, daily, unremitting from onset (or within 3d of onset) typically in patients without history of headache

  • Secondary:

    • Infection: Meningitis, sinus, mastoid, dental

    • Hypertension: Preeclampsia

    • Systemic illness

      • Carbon monoxide

  • Intracranial:

    • Vascular: Subarachnoid hemorrhage (thunderclap), Temporal arteritis, Venous Sinus Thrombosis, SDH (worsening over time), Cervical artery dissection (TIA/neuro deficit in young)

    • Nonvascular: Increased/decreased (eg. CSF leak) ICP, Tumor, Chiari malformation (Valsalva)

  • Extracranial:

    • Eye disorder (refractory errors, glaucoma), Carotid dissection, TMJ

Physical Exam

  • Vitals including BP

  • Neurological exam

    • Mental status

    • Cranial nerve (including fundoscopy)

    • Unilateral limb weakness, reflex asymmetry, coordination in arms

    • Gait, heel-toe walking

  • Consider neck and oropharynx exam


  • Neuro exam, fundoscopy r/o increased ICP

  • CT if red flags or risk of intracranial pathology

  • Lumbar puncture if symptoms of secondary cause

      • Valsalva/exercise, systemic illness (fever/rash/neck stiffness/meningismus), neuro sign (papilledema/seizure)

  • Consider ESR/CRP if suspect temporal arteritis

  • Consider CT/LP to rule out subarachnoid hemorrhage (SAH)

    • Ottawa SAH Rule (100% sensitive, 15% specific - if negative helpful to rule out, excluded neuro deficits, brain tumors, chronic recurrent headache)

      • Age≥40, Neck Pain/Stiffness, LOC, Onset during Exertion, Thunderclap, Limited Neck Flexion on exam

    • CT (diagnosis 90% SAH within 24h)

      • Lumbar Puncture (If negative CT)

        • Elevated opening pressure, elevated RBC count that does not significantly diminish, Xanthochromia (hemoglobin degradation if blood in CSF >2h)

        • If diagnosed SAH, proceed to angiography to rule out aneurysmal


  • Keep headache diary, record frequency, intensity, triggers, medication

  • Lifestyle changes

    • Reduce caffeine

    • Regular aerobic exercise

    • Avoid irregular/inadequate sleep or meals

    • Avoid triggers

    • Fluids

  • Stress management

    • Relaxation training

    • CBT

    • Pacing activity

    • Biofeedback therapy

  • Acupuncture

  • Transcutaneous electrical nerve stimulation


  • Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg

  • Second Line: Triptans (eg. Sumatriptan 100mg PO)

    • Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans

    • Contraindicated in CV diseases, pregnancy, ergots

  • Consider Gepants (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)

  • Prophylaxis if 4+/month, or >12h, or increased in frequency or rebound (trial of at least 2 months needed, treat for 6-12 months then taper to reassess need)

    • Betablocker (Propranolol, Metoprolol, Timolol), Antidepressants (Amitriptyline, Venlafaxine), Anticonvulsants (Valproate, Topiramate)

    • Less evidence:

      • Calcium channel blockers (Verapamil)

      • Melatonin 3mg (as effective as amitriptyline in one RCT)

      • Riboflavin (Vit B2) 400mg/d after three months

  • ER IV cocktail: 1L bolus NS, Prochlorperazine 10mg, Diphenhydramine 25mg , Ketorolac 30mg, Dexamethasone 10mg


  • Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg

  • Prophylactic: TCA (Amitriptyline, Nortriptyline)


  • 100% oxygen 12L/min x 15 mins through non-rebreather mask

  • Sumatriptan 6mg subcutaneous, Zolmitriptan 5mg intranasal

    • Triptans contraindicated in Cardio/Cerebrovascular disorders

  • Bridge with Corticosteroids (prednisone), Ergotamine, Occipital nerve block

  • Prophylactic Verapamil 240-480mg/d or steroids

  • Early specialist referral

Medication overuse

  • Stop offending medication

    • Can bridge with NSAID (naproxen) or prednisone

Hemicrania Continua or Daily Persistent Headache

  • Indomethacin

  • Specialist referral

  • Consider MRI Brain