For many people living with headache, primary care is the first point of contact and the foundation for ongoing care. A focused, structured approach can support accurate diagnosis, appropriate use of resources, and treatment plans that evolve with the patient’s needs.
- Migraine disease is the most common diagnosis with an estimated prevalence of approximately one-third of patients (between 28% and 34%) seen in US primary care settings for any complaint.
- 70% – 75% of those who live with migraine disease are women between ages 25 to 55 years.
Initial Evaluation (Ideally a Dedicated Appointment)
A dedicated headache visit allows time for a complete clinical assessment and establishes a baseline for long-term management. The goal is to define the headache phenotype, rule out secondary causes, and understand the patient’s functional burden.
Earlier Life and Pattern Evolution
Begin by exploring how the headache disorder developed over time:
- Age at onset, headache pattern, and description of headache attacks
- Changes in frequency, severity, or character
- Family history of migraine or other headache disorders
This historical context often helps distinguish primary headache disorders from secondary causes and frames the current presentation.
Current Headache Characteristics
Ask patients to describe the features of their typical attacks:
- Location and sidedness of pain
- Quality of pain (throbbing, pulsating, pressure-like)
- Aggravation by routine physical activity
- Typical pain intensity (0–10 scale)
- Frequency and number of headache-free days in the past 30 days
- Duration of each attack
- Time of day headaches most often begin
These elements help clarify diagnosis and guide selection of acute and preventive therapies.
Associated Symptoms
Associated features and medication patterns provide important diagnostic and management insights:
- Sensitivity to light and sound, nausea or vomiting, syncope, vertigo, allodynia
- Blurry spots, zigzag lines, paresthesia, asthenia
- Other neurologic/systemic systems
Treatment History
This step is important for identifying possible medication overuse and unmet treatment needs, and patient’s perceived effectiveness and tolerability of each:
- Frequency of over-the-counter analgesic use including combination pain relievers
- Use of prescription NSAIDs, triptans, or other pain relievers
Red Flags and Imaging Considerations
Before finalizing a diagnosis, screen for secondary headache features using tools such as SNOOPP:
- Systemic symptoms or illness
- Neurologic deficits
- Onset sudden or thunderclap
- Older age at onset
- Progressive or changing pattern
- Positional or precipitated headache attacks
In patients with recurrent headache consistent with migraine, a normal neurologic examination, and no red flags, routine neuroimaging is generally not indicated.
Functional Impact and Disability
Understanding how headache affects daily life helps determine treatment urgency and goals:
- Missed work or school
- Reduced ability to participate in daily or social activities
- Impact on concentration, sleep, or mood
This functional assessment supports shared decision-making and individualized care planning.
Diagnosis and Treatment
Once diagnosed, the goal for acute treatment is to be headache- free. For a diagnosis of migraine, this means back to full function within 2 hours.
- Over-the-counter analgesics include 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, and gepants.
- Note: Barbiturates 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.
Tracking – Diary (App or Manual)
Encourage patients to use a headache diary to move beyond symptom recall and create a shared clinical record that supports treatment decisions over time.
What to Track
Have patients consistently record:
- Duration and intensity of each attack
- Frequency, including headache-free days
- Functional impact, such as missed work or activities
- Potential triggers (e.g., stress, sleep changes, dietary factors, hormonal patterns)
- All treatments used, including over-the-counter medications, prescriptions, supplements, and lifestyle strategies
Clinical Value
Over time, this record helps identify patterns, assess treatment effectiveness, and guide stepwise adjustments to both acute and preventive care.
Timely Follow-Up
Follow-up visits are an opportunity to review progress, reinforce effective strategies, and refine the treatment plan based on patient goals and clinical response.
- Action Plan: Develop a clear, patient-centered plan that reflects priorities and preferences, including when and how to use acute treatments and what steps to take if symptoms escalate.
- Treatment Optimization: Use the diary to guide clinical decisions:
- Acute treatment: Continue, modify, or discontinue therapies based on effectiveness, tolerability, and frequency of use
- Preventive treatment: Consider options when headaches are frequent, disabling, or poorly controlled
- Reconsideration of Diagnosis: If a patient is not finding relief from several different acute treatments, then reconsideration of the diagnosis may be warranted or referral.
Referral Considerations
Referral to a neurologist or headache specialist should be considered when there are atypical features, diagnostic uncertainty, failure to respond to recommended migraine management strategies, or comorbidities requiring more complex care.
Aligning with Clinical Guidance
This workflow aligns with principles outlined in the American Headache Society’s First Contact Algorithm for Migraine, which emphasizes structured history-taking, appropriate use of imaging, patient tracking, and evidence-based treatment pathways in the primary care setting.