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  • image Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school, or work.

  • image A stratified care approach, in which the selection of initial treatment is based on headache-related disability and symptom severity, is the preferred treatment strategy for the patient with migraines.

  • image Strict adherence to maximum daily and weekly doses of anti-migraine medications is essential.

  • image Preventive therapy should be considered in the setting of recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective, contraindicated, or produce serious side effects; and uncommon migraine variants that cause profound disruption and/or risk of neurologic injury.

  • image The selection of an agent for headache prophylaxis should be based on individual patient response, tolerability, convenience of the drug formulation, and coexisting conditions.

  • image Each prophylactic medication should be given an adequate therapeutic trial (usually 6 months) to judge its maximal efficacy.

  • image A general wellness program and consideration of headache triggers should be included in the management plan.

  • image After an effective abortive agent and dose have been identified, subsequent treatments should begin with that same regimen.


Patient Care Process for Headache Disorders



Subjective and Objective data

  • Presence of other symptoms

    • Nausea

    • Vomiting

    • Sensitivity to light, sound, and/or movement

  • Identification of triggers or aura (Table 78-6)

  • Patient characteristics (eg, age, sex, pregnant)

  • Patient medical history (personal and family)

  • Social history (smoking, diet, physical activity)

  • Description of migraine/headache pain (including frequency and location)

  • Presence of diagnostic alarms

    • Acute onset of the “first” or “worst” headache ever

    • Accelerating pattern of headache following subacute onset

    • Onset of headache after age 50 years

    • Headache associated with systemic illness (eg, fever, nausea, vomiting, stiff neck, and rash)

    • Headache with focal neurologic symptoms or papilledema

    • New-onset headache in a patient with cancer or human immunodeficiency virus (HIV) infection

Medication History

  • Current use, dosage, and frequency of medications (especially over the counter [OTC] aspirin/nonsteroidal anti-inflammatory drug [NSAID] use, herbal products, and dietary supplements) (Tables 78-4 and 78-5)

Diagnostic Tests

  • Consider neuroimaging studies in patients with abnormal neurologic examination findings of unknown etiology and in those with additional risk factors warranting imaging

  • Physical Exam

  • Neurological Exam

  • Diagnostic abnormalities (Table 78-2)

    • Vital signs (fever, hypertension)

    • Funduscopy (papilledema, hemorrhage, and exudates)

    • Palpation and auscultation of the head and neck (sinus tenderness, hardened or tender temporal arteries, trigger points, temporomandibular joint tenderness, bruits, nuchal rigidity, and cervical spine tenderness)

    • Deficits in mental status, cranial nerves, deep tendon reflexes, motor strength, coordination, gait, and cerebellar function


Initial Assessment

  • Type of headache, acute or chronic (Table 78-1)

  • Other contributing factors (eg, presence of anxiety, depression, or medication over use)

Medication Assessment

  • Evaluate need for therapy

  • Evaluate current therapy for appropriateness, response, side effects, and medication adherence

  • Evaluate other therapy options (compare/contrast based on safety, efficacy, cost/coverage by insurance)


  • Acute ...

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