Algorithm Based Approach To Headache.5

Review Article
Algorithm-based approach to headache

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Jayaprakash R. Ravan, Jigyansa I. Pattnaik, Swayanka Samantray

Department of Psychiatry, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 08/08/2024
A bstract
One of the most commonly encountered scenarios in any healthcare setting is a patient presenting with a headache. Yet, the
assessment, diagnosis and treatment of headache disorders can be challenging and burdensome for even specialist doctors in
medicine, psychiatry, oto‑rhinology, neurology and so on. Apart from saving patient’s and doctor’s time as well as money, this
article will buy leading time for better outcome and management of certain difficult headache disorders. The aim of this review is
to simplify the approach to headache diagnosis for an early and proper referral. Literature search was done on PubMed and Google
Scholar using key words. Only studies which were in English were considered. Sixty‑one articles published from 1975 to 2022
were reviewed after screening for inclusion and exclusion criteria. It is very essential that a primary care physician is aware of the
classification of headache. Red flag signs of high‑risk headaches are essential for proper referral. It is also essential that we rule
out secondary headaches as they are more life threatening. Vulnerable populations such as geriatric and paediatric populations
require expert attention in case of headache disorders.
Keywords: Cluster, headache, migraine, primary care, tension type, treatment
Introduction any underlying aetiology and secondary headache disorders may

be due to specific causes [Table 1].[5] Headaches can be seen in
Headache may be described as a disabling and painful people irrespective of their races, socio‑economic status and age.
characteristic of primary headache disorders that include However, it is more commonly prevalent in the female sex.[3]
cluster headache (CH), tension‑type headache (TTH), migraine
and chronic daily headache syndromes.[1] The World Health One of the most commonly encountered scenarios in any
Organization (WHO) has reported that in any given year, nearly healthcare setting is a patient presenting with a headache. Yet,
one‑half of the adult population in the world will suffer from the assessment, diagnosis and treatment of headache disorders
a headache disorder. This shows it has a tremendous effect can be challenging and burdensome for even specialist doctors
on ‘public health’.[2] It is a common universal symptom that in medicine, psychiatry, oto‑rhinology, neurology and so on.
has varied and complex causes.[3] The Ad Hoc Committee on The sole purpose of this review is to simplify the approach to
Classification of Headache has classified headache into as many headache diagnosis for an early and proper referral. Apart from
as 15 categories.[4] The second edition of the International saving patient’s and doctor’s time as well as money, this article
Classification of Headache Disorders (ICHD‑2) has classified will buy leading time for better outcome and management of
headache disorders depending on aetiology into primary and certain difficult headache disorders.
secondary headaches. Primary headache disorders are without
Materials and Methods
Address for correspondence: Dr. Swayanka Samantray,
Plot‑10, Rabindra Garden, Soubhagyanagar, Unit‑8, Bhubaneswar, Literature search (eligibility criteria, information sources and search):
Khurdha ‑751 003, Odisha, India. A complete literature search was done to identify population‑based
E‑mail: [email protected]
research work on different types of headache and their
Received: 03‑08‑2022 Revised: 22‑09‑2022 management. PubMed and Google Scholar were used to search
Accepted: 04‑10‑2022 Published: 30-09-2023
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DOI: How to cite this article: Ravan JR, Pattnaik JI, Samantray S.
10.4103/jfmpc.jfmpc_1553_22 Algorithm-based approach to headache. J Family Med Prim Care
2023;12:1775‑83.
© 2023 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 1775
Ravan, et al.: Algorithm‑based approach to headache
the following key words: primary care, migraine, headache, ICHD third edition (beta version)
treatment, cluster, tension type. Most articles were published Primary headaches
from 1970 to 2022, and only English language was considered. Although primary headache disorders are not life threatening,
Only online articles were included in the review. they are responsible for high disability‑adjusted life years (DALY)
and morbidity. The true magnitude of public health burden of
Data extraction (data collection process): The information headache has not been fully acknowledged until now. Headache
extracted included the types of headache, their prevalence, causes huge loss to society indirectly through loss of work
their classification, diagnosis and management. Also, time. Like any other chronic disorder, headaches cause loss
information about diagnosis and management of various of quality of life, disability and morbidity at an individual
types of headache in special populations based on age group level. [7] DALY due to primary headaches can be reduced
was also included. by early identification [Figure 1] and swift evidenced‑based
management [Table 2].

Study selection
All studies published from 1975 to 2022 that were available On the other hand, secondary headaches are mostly acute and
online were selected. Out of 80 articles screened, 61 were subacute, life threatening and tagged with mortality. The doctor in
included. Studies which were in language other than English medicine outpatient department (OPD) or a resident in casualty/
were excluded, and those that did not have access were also community health centre (CHC)/ first referral uni (FRU) needs to
excluded. Only those articles in which headache diagnosis be quick and rational while evaluating a case of headache, and it
was according to the International Classification of Headache is essential that a detailed clinical examination is done to rule out
Disorders‑1 (ICHD‑1) or ICHD‑2 or ICHD‑3 were included. secondary headaches. (a) Neurogenic headache is acute, abrupt
Although ICHD‑1 appeared in 1988, we also included studies and holocranial, associated with infection/head trauma, rigidity
on headache prevalence before 1988. of the neck, localising signs, vomiting and so on. (b) Ear, nose and
throat (ENT) headaches are associated with vertigo, giddiness,
Data items otalgia, sinusitis and rhinitis. (c) Ophthalmological headaches are
Population: We selected studies that were performed in a sample associated with signs and symptoms of glaucoma and refractive
representative of the whole population. We also included studies errors. (d) Psychogenic headaches are mostly caused by sleep
disturbance, untreated mood disorders/psychotic disorders, as
on special populations such as geriatric and paediatric age groups.
well as substance withdrawal syndrome [Figure 2].
Studies based on specific populations such as clinic population/
college students/pregnant women were not included.
Secondary headaches require specialist consultation [Figure 1].
In neurogenic secondary headache, investigations such
Intervention: Studies describing various types of pharmacotherapy
as computed tomography (CT) scan, magnetic resonance
for headache, including oral medications as well as parenteral
imaging (MRI) and so on are done to rule out haemorrhages/
medication of primary headache particularly, were included.
infarct/space‑occupying lesions (SOLs)/any other neurological
Studies exploring neurostimulation methods for treatment of
abnormality. In ENT headaches, speculum examination,
primary headache were included. All articles describing acute
otoscopy, nasal endoscopy, CT scan para-nasal sinuses (PNS)
as well as prophylactic management of primary headache were
and so on are performed. Ophthalmological headaches
included.
Comparison or control: May be or may not be present. Headache
Outcome: Reduction of headache.
Study design: Systematic reviews, meta‑analysis, randomised PRIMARY HEADACHE SECONDARY HEADACHE
1. Tension-type (with & without 1. Infections (systemic/ HIV/ post-infection/
controlled trials (RCTs) as well as other narrative reviews were tenderness- peri-cranial) meningitis)
included. Case series and case reports were not included. 2. Cluster headache 2. Vascular (A-V fistula/post-CVA/
3. Migraine (with & without non-traumatic SAH/malformations/
aura, retinal, periodic aneurysm/TIA)
Epidemiology and Classification symptoms in children)
4. Other (exercise, sexual
3. Head trauma (subdural/epidural/
whiplash/ neck injury/ post craniotomy)
activity, cough) 4. Decreased CSF Pressure
Primary chronic daily headache syndrome has been divided into 5. Increased CSF pressure (SOL/
hydrocephalus/ idiopathic raised ICT)
chronic TTH, migraine, new daily persistent headache (NDPH) 6. Addiction- drug intake & withdrawal
and hemicranias continua (HC). They comprise almost 98% of (sildenafil /alcohol /estrogen withdrawal/
medication overuse)
all headache disorders.[6] Although secondary headaches are more 7. Others (ENT/ophthalmology)
serious and can end up in life‑threatening scenarios, most of 8. Psychiatry- somatization/depression.
the time, he adaches are treatable with lifestyle changes and/or

medications.[3] Figure 1: Classification of headache (based on aetiology)
Journal of Family Medicine and Primary Care 1776 Volume 12 : Issue 9 : September 2023
require slit‑lamp examination, refractory error examination, Childhood Headache

fundoscopy, ophthalmoscopy and so on [Table l]. Psychogenic
headaches can be diagnosed with detailed clinical history and In one study, it was found that 24%–90% of children present
Mental Status Examination (MSE). with headache as a symptom and the total prevalence is about
58.4% among children.[33] Among the school‑going children,
High‑Risk Headaches or Dangerous prevalence is equivalent in girls and boys,[33] rises with age in
both genders and the surge is more in females than males
Headaches
during adolescence. The most common primary headache

It is difficult to distinguish high‑risk headaches from benign among children is none other than migraine.[34] Its prevalence
ones because there are overlapping signs and symptoms.[8] in childhood is around 7.7%; however, it is underdiagnosed
The high‑risk headaches are associated with certain red flag among children.[33] Cluster headaches as well as paroxysmal
symptoms that are mostly established by consensus reports hemicranias, which are trigeminal autonomic cephalgias, are rare
and observational studies. Thus, they may not be unequivocally among children.[34] TTH is also seen in children with a prevalence
precise in determining the severe underlying aetiologies among of 5%–25%, and the age on onset is equivalent to 7 years. It
patients with headache. Hence, patients showing features of may be precipitated by various psychosocial stressors as well
secondary headaches should be examined and investigated as comorbid psychiatric disorders such as anxiety and mood
thoroughly to rule out any high‑risk pathology. Various illnesses.[35] In the paediatric group, secondary headaches occur
radiological examinations are available to make this task easier, mostly due to acute infections such as sinusitis, upper respiratory
such as CT scan and MRI. MRI is much more sensitive in tract infection (RTI), systemic infections and so on. In a few
identifying smaller lesions.[9] cases, they may be due to chronic intracranial illnesses such as
Table 1: Differential diagnosis of secondary headache

Diagnosis Symptoms Signs Investigation
Cervicogenic Non‑throbbing headache, starting in the Precipitated by movement, reduced range X‑ray
headache[7] neck of neck movement, neck/shoulder/arm
Duration‑ varied pain‑ ipsilateral, no side shift
Giant cell Age at onset >50 years Tender, thickened, reduced pulsation
ESR >50 mm/h
arteritis[7,14] Onset‑ abrupt unilateral/bilateral headache, in superficial temporal artery, scalp
Arterial biopsy‑ vasculitis characterised by
scalp tenderness, visual symptoms‑ diplopia, tenderness, visual field defect, vascular
mononuclear cell infiltration, multinucleated
blurred vision/loss, limb claudication, bruit giant cells
constitutional symptoms‑ fever, malaise, Fundoscopy
fatigue, weight loss Optic disc‑ pale and swollen with haemorrhage
Idiopathic Daily, non‑pulsating, diffuse headache Papilloedema, visual field defect, enlarged LP‑CSF pressure >200 mm of
intracranial increased by coughing, straining blind spot, sixth nerve palsy H2O (non‑obese)
hypertension[14] >250 mm of H2O (obese)
MRI, CT
Post‑traumatic Headache except any typical features within CT with bone window images
headache[14] 7 days after head trauma X‑ray‑ fracture, ligamentous injury of spine,
subluxation
Cranial MRI‑ focal
contusion‑ non‑haemorrhagic
Subarachnoid Intense, incapacitating abrupt‑onset Neck rigidity, altered mentation CT scan‑ haemorrhage
haemorrhage[15] headache associated with vomiting MRI
CSF examination if scan is normal
Angiography
Central venous Headache with no specific features Seizure, signs of raised intracranial MRI along with MRV venous thrombosis
thrombosis[15] tension, focal neurological signs
Trigeminal Unilateral, onset‑ abrupt, electric shock‑like Neurological deficit‑ absent MRI‑ vascular/non‑vascular
neuralgia[16] sensations, duration‑ seconds to 2 min, Compression of fifth cranial nerve
along distribution of the fifth cranial
nerve (second, third divisions), pain
induced by washing, brushing, smoking,
talking
Acute glaucoma Painful red eye, sudden blindness/blurred Clouding of cornea, conjunctival Elevated IOP>28 mmHg
vision injection, visual disturbances
Acute sinusitis Frontal headache, pain in ear, face and teeth Sinus tenderness Elevated ESR, polymorphonuclear
leucocytosis
Pus culture‑ organism isolated
X‑ray‑ shadow/fluid level
CSF=cerebrospinal fluid, CT=computed tomography, ESR=erythrocyte sedimentation rate, IOP=intraocular pressure, MRI=magnetic resonance imaging, LP-CSF=Lumbar puncture-cerebro-spinal fluid, MRV=Magnetic
resonance venography
Headache
H/o site, quality, intensity, duration and course, associated

features, aggravating and relieving factors
Leading questions for ruling out trauma/infections/ malformation/local

tenderness/cerebrovascular accident/addiction/drugs/psychiatric/
oto-rhino-laryngologic/ophthalmological causes
NO
Detailed ENT, ophthalmological, psychiatric
and neurological evaluation
Primary
headache
a. Seizure,
b. visual acuity, Refer to
YES
c. localising NEUROLO
sign, GIST
d. vomiting but to rule
a. Periodic and
no nausea, out SOLs
excruciating
a. Pulsating, e. papilloedema
retro-orbital
severe,
pain
b. peaks over a. Reduced
b. Explosive a. Severity-
hours to days, vision,
and non- mild to Refer to
c. relieved b. conjuctival
fluctuating moderate OPHTHAL-
by rest, congestion
c. duration- b. Pressing MOLOGIST
d. aura, c. Pupil- dilated
short c. Duration- Secondary to evaluate
motionless, and fixed
d. Onset- min to headache for glaucoma
e. associated d. Cupping of
nocturnal weeks
with nausea, disc-increased
(50%) d. Bilateral
vomiting, Refer to
e. Pain-free
photophobia, ENT
intervals, Vertigo,
phonophobia to rule out
restlessness dizziness, BPPV/
f. M:F = 3:1 nystagmus labrynthitis/
sinusitis
a. Depression,
b. suicidal Refer to a
behaviour, PSYCHIATRIST
CLUSTER TENSION c. substance
MIGRANE
TYPE TYPE abuse
Figure 2: Approach to a case of headache[10-13], BPPV: Benign paroxysmal positional vertigo
meningitis, encephalitis, brain abscess, brain tumours, SOLs, nonsteroidal anti‑inflammatory drugs (NSAIDs) such as
idiopathic intracranial hypertension, hydrocephalus, vascular paracetamol and/or ibuprofen adjusted to paediatric doses.[39]
malformations and others. [36,37] It has also been seen that For acute management of migraine with and without aura
unhealthy lifestyles lead to increased incidence of childhood among children, triptans can be given along with NSAIDs.
headache, for example, high parental expectations, increased For nausea and vomiting, domperidone, prochlorperazine
academic pressure, overinvolvement in extracurricular activities, and cyclizine may be added.[40] For trigeminal autonomic
increased screen time, cut‑throat competitions, poor nutrition cephalgias (TACS), high‑flow oxygen at 12 L/min has been
and reduced sleep.[38] Red flags and the approach to headache recommended. [39] Prophylactic management of primary
evaluation among children are similar to those of the adult headaches is more or less same in children as in adults.
population.
Headache in Geriatric Age Group
Management of Childhood Headache The prevalence of headache in older population is around
Non‑pharmacological management 12%–50%.[41,42] Headache among elderly population is mainly
due to primary headache such as migraine and TTH. However,
The child is advised to stay in a dark and quiet room in order to
the risk of secondary headache increases among elderly.[42,43]
rest. Sleep and hydration often help.[35] SMART is an acronym The risk of dangerous or high‑risk headache rises 10 times
which consists of various lifestyle modifications that can help among those aged 65 years and above.[42] It has been observed
in the management of childhood headache. that secondary aetiologies such as vascular events cause sudden
deaths among elderly, especially intracranial haemorrhage,
Pharmacological management rupture of aneurysm and cervical arterial dissection. In
First‑line acute pharmacological treatment of primary the presence of red flag signs, investigations among elderly
headaches, especially TTH, among children involves population may vary and they should comprise various blood
Table 2: Management of primary headaches

Type of primary headache Treatment available
Migraine First‑line pharmacotherapy[18‑23]
Acute treatment Combination of analgesics:
aspirin (250 mg)/caffeine (65 mg)/acetaminophen (250 mg)
Combine triptans and NSAIDs:
naproxen (500 mg)/sumatriptan (85 mg) (maximum dose: two tablets/day)
Triptans
Almotriptan, rizatriptan, eletriptan, frovatriptan, sumatriptan, naratriptan, zolmitriptan
NSAIDs:
Naproxen (250-500 mg orally 12 hourly, maximum dose‑ 1 g/day)
Ibuprofen (200-800 mg orally 6-8 hourly, maximum dose‑ 2.4 g/day)
Other effective pharmacotherapies[18‑23]

Ergotamines: dihydroergotamine
Acetaminophen (325 mg)/isometheptene (65 mg)/dichloralphenazone (100 mg)
Antiemetics: metoclopramide, prochlorperazine
Dexamethasone IV
Lidocaine IV
5‑HT1F agonist, lasmiditan[24]
Calcitonin gene-related peptides such as rimegepant or ubrogepant[24]
Injectable[17]
Subcutaneous sumatriptan
Neurostimulation[17]
TMS.
VNS
External trigeminal nerve stimulation
Preventive treatment[17] Oral and intranasal
ARBs: lisinopril, candesartan
Beta‑blockers: propranolol, metoprolol, timolol, atenolol, nadolol
CCBs: “flunarizine “
Anticonvulsants: topiramate, valproate
Antidepressants:
Tricyclics: amitriptyline
SNRI: venlafaxine
Nutraceuticals: “riboflavin, coenzyme Q10, magnesium, omega3, vit‑D[25]
Injectables
CGRP pathway monoclonal antibodies
Onabotulinumtoxin‑A
Neurostimulation
External trigeminal nerve stimulation
Occipital nerve stimulation
High cervical spinal cord stimulation
Transcranial magnetic stimulation
Tension‑type headache Level A recommendation[28]
Acute treatment[26,27] Ibuprofen 200-800
Ketoprofen 25 mg
Aspirin 500-1000 mg
Naproxen 375-550 mg
Diclofenac 12.5-100 mg
Paracetamol 1000 mg (oral)
Level B recommendation[28]
Caffeine comb. 65-200 mg
Prophylactic treatment[26] First line
Amitriptyline. 30-75 mg
Second line
Mirtazapine.30 mg
Venlafaxine.150 mg
Third line
Clomipramine 75-150 mg
Maprotiline 75 mg
Mianserine 30-60 mg
Contd...
Table 2: Contd...
Type of primary headache Treatment available
Non‑pharmacological Psycho-behavioural treatments:
treatment[26] EMG biofeedback
Relaxation training
Cognitive-behavioural therapy
Cluster headache Triptans
Acute treatment[29‑31] Sumatriptan S/C (6 mg)

Zolmitriptan nasal spray. (5 and 10 mg)
Sumatriptan nasal spray. (20 mg)
Zolmitriptan. orally (10 mg)
Oxygen
High‑flow mask (flow rate of 12-15 L/min, sitting position)

Lidocaine nasal spray ipsilateral nostril at 4% and 10%
Prophylactic treatment[29‑31] Verapamil
360 and 560 mg/day, increased to up to 960 mg/day
Lithium 0·6 and 0·8 mmol/L
Topiramate 100 and 200 mg/day (monotherapy or add on to verapamil)
Prednisolone
Triptans‑ frovatriptan, or naratriptan
Melatonin
Calcitonin gene-related peptide monoclonal antibodies[32]
Suboccipital blockade‑ greater occipital nerve with a mixture of lidocaine and a steroid (i.e. dexamethasone)
Non‑invasive vagus nerve stimulation
Spheno‑palatine ganglion micro stimulator
ARBs=angiotensin pathway blockers, CCBs=calcium channel blockers, EMG=electromyography, IV=intravenous, NSAIDs=nonsteroidal anti‑inflammatory drugs, TMS=transcranial magnetic.stimulation, VNS=vagal
nerve stimulation, SNRI=Serotonin and norepinephrine reuptake inhibitors, CGRP=Calcitonin gene related peptide
Secondary headaches
1. Migraine a. Trauma to the head and/or neck
b. Cervical and/or cranial vascular disorder

2. Tension-type headache
c. Intracranial disorder - non-vascular
d. A substance or its withdrawal

3. Trigeminal autonomic cephalalgias
e. Infection
4. Other primary headache disorders[7] f. Homoeostasis disorder
g. Disorder of eyes, ears, cranium, neck, teeth, mouth, sinuses, nose

or other facial or cranial structure
Primary headache
h. Mental health disorders[7]
tests including erythrocyte sedimentation rate (ESR) and

neuroimaging techniques to rule out vascular anomalies or
Secondary headache
tumours/SOLs.[44] Most importantly, chronic disorders such
as hypertension and type 2 diabetes mellitus should also be
ruled out.
Discussion
The approach of a doctor should be to get a thorough
Once secondary headache disorders are ruled out, primary history of headache, which consists of the type, site, intensity
headache may be diagnosed. [44] Among those aged above and frequency, aggravating and relieving factors, course,
55 years, the 1‑year prevalence was found out to be 35.8% in duration and other associated characteristics. With available
a review article.[45] It has been observed that there is higher information, the next step is to ask leading questions in order to
risk of TTH among patients with depression, overuse of pain differentiate primary and secondary headache [Figures 1 and 2].
medication, as well as chronic pain and frequent headaches.[45] Arriving at a conclusion is very essential to plan further
Among older adults, migraine is the second most common management [Table 2] or referral. Following guidelines
headache and the 1‑year prevalence is around 10%. [43,46] helps to save time and avert confusion. A case of secondary
Treatment of primary headache among older adults is similar headache may require further neurology/ophthalmology/
to that of younger adults. ENT/psychiatric consultation depending on the history and
Red flag symptoms of high-risk headaches:[9,47-51] Non-pharmacological management of childhood headache

a) Headache is the worst one in the patient’s life SMART stands for
b) Neck stiffness or meningismus S- sufficient Sleep,
c) Certain focal neurological signs (excluding typical aura) M- healthy Meals,
d) Age >50 years A- optimum Activity,
e) Rapid-onset headache due to rigorous exercise R- proper Relaxation and
f) New onset of severe headache during pregnancy/postpartum T- avoiding Triggersa[40]
g) Papilloedema a
Triggers include excess caffeine, chocolate, nitrite, alcohol-containing
h) Temporal artery tenderness food and monosodium glutamate (MSG) from their diet, screen time
i) Worsening pattern
j) Rapid/sudden onset (thunderclap headache, peak in intensity within Non-pharmacological management of childhood headache
seconds or minutes)
k) Headache associated with systemic disease (fever, rash)
l) Headache precipitated by exertion/cough/sexual intercourse Peculiarities of primary headache in elderly
m) Headache associated with altered personality/mental status/level Elderly migraine:

of consciousness The characteristic features change as the patient gets older
n) New headache type in a patient with cancer, Lyme disease, Symptoms such as phonophobia, photophobia, nausea and vomiting
HIV infection decrease, but rhinorrhoea and lacrimation increase.[57,58] Neck pain
HIV = human immunodeficiency virus is more common among older adults, and if the migraine is of late
onset, aura without headache occurs more commonly[58]
Red flag symptoms of high risk headaches Hypnic headache:
A primary headache type described as a headache disorder that occurs
for short duration mostly in older population >50 years of age
‘Medication overuse headache (MOH) in elderly’ As they occur during sleep, they awaken the person and in order to be
Defined as headache that occurs more than or equal to 15 days/month diagnosed as hypnic headaches, they must occur for ≥15 days per
due to overuse of medication[52] month[52]
Certain non-analgesics also cause MOH, such as nifedipine, More common in females and in the age group ≥60 years[59,60]
dipyridamole, nitroglycerine, proton-pump inhibitors and SSRIs[53,54]
Medication overuse was responsible for 19% of chronic TTH as well as Headache in elderly
31% of chronic migraine[55]
What can be done? Analgesic medications used for various pains
should be prescribed only for limited time in order to prevent MOH[56] NDPH = new daily persistent headache
It is essential to be vigilant about MOH in case of poly-pharmacy as HC = hemicranias continua
well as deranged pharmacokinetics due to altered liver and/or renal
function among older adults.[44]
PHC = primary health care
CHC = community health centre
Medication overuse headache SOLs = space‑occupying lesions
examination [Table 1]. It is equally important that we identify Financial support and sponsorship
the red flag signs and do the needful.
Nil.
Limitations Conflicts of interest
This review only includes the studies written in English language; There are no conflicts of interest.
so, several data are not included due to language constraint.
Also, only reports available online are included in the study.
Management of secondary headache could not be discussed
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Review Article

Algorithm-based approach to headache

Jayaprakash R. Ravan, Jigyansa I. Pattnaik, Swayanka Samantray

Keywords: Cluster, headache, migraine, primary care, tension type, treatment

Introduction any underlying aetiology and secondary headache disorders may

management [Table 2].

Comparison or control: May be or may not be present. Headache

Outcome: Reduction of headache.

the time, he adaches are treatable with lifestyle changes and/or

require slit‑lamp examination, refractory error examination, Childhood Headache

during adolescence. The most common primary headache

Table 1: Differential diagnosis of secondary headache

H/o site, quality, intensity, duration and course, associated

Leading questions for ruling out trauma/infections/ malformation/local

Figure 2: Approach to a case of headache[10-13], BPPV: Benign paroxysmal positional vertigo

Table 2: Management of primary headaches

Other effective pharmacotherapies[18‑23]

Acute treatment[29‑31] Sumatriptan S/C (6 mg)

High‑flow mask (flow rate of 12-15 L/min, sitting position)

1. Migraine a. Trauma to the head and/or neck

b. Cervical and/or cranial vascular disorder

d. A substance or its withdrawal

4. Other primary headache disorders[7] f. Homoeostasis disorder

g. Disorder of eyes, ears, cranium, neck, teeth, mouth, sinuses, nose

tests including erythrocyte sedimentation rate (ESR) and

Red flag symptoms of high-risk headaches:[9,47-51] Non-pharmacological management of childhood headache

m) Headache associated with altered personality/mental status/level Elderly migraine:

List of abbreviations 6. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily

Neuroradiol 2007;28:1085‑7. A systematic review of the literature. Clin Neuropharmacol

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