Practice Guidelines
Outpatient Primary Care Management of Headaches: Guidelines from the VA/DoD
Am Fam Physician. 2021 Sep ;104(2):316-320.
Author disclosure: No relevant financial affiliations.
Key Points for Practice
• Ibuprofen and high-dose acetaminophen improve acute tension-type headaches. Amitriptyline is effective at preventing tension-type headaches after three months of treatment.
• Triptans, ibuprofen, naproxen, aspirin, and high-dose acetaminophen are effective treatments for acute migraine. Intravenous magnesium and greater occipital nerve blocks are also effective.
• Effective migraine preventive medications include candesartan, telmisartan, lisinopril, oral magnesium, topiramate, propranolol, erenumab, fremanezumab, and galcanezumab.
• Galcanezumab reduces cluster headache frequency, whereas triptans and oxygen may improve acute cluster headaches.
From the AFP Editors
Headache disorders affect two-thirds of people in their lifetime, and a large number of potential treatments exist. The U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) published updated guidelines for the treatment of headache disorders based on a systematic review.
Secondary Headaches
Secondary headaches are caused by an identifiable process. Cervicogenic headache, posttraumatic headache, and medication overuse headache are the most common secondary headaches. Red flag symptoms (Table 1) suggest a secondary headache etiology requiring urgent investigation. Primary headaches are diagnosed when a secondary cause cannot be identified (Figure 1).
Red Flags for Secondary Headache (SNOOP4E)
Systemic symptoms, illness, or condition (e.g., cancer, chills, fever, immunocompromise, infection, myalgias, night sweats, pregnancy or postpartum, weight loss) |
Neurologic symptoms or abnormal signs (e.g., confusion, diplopia, focal neurologic signs, impaired consciousness, meningismus, pulsatile tinnitus, seizures) |
Onset occurs with maximal intensity within minutes or “thunderclap” headache |
Older (age ≥ 50 years at onset) |
Progression (e.g., change in features, pattern, severity) |
Precipitated by Valsalva |
Postural aggravation |
Papilledema |
Exertional provocation |
Red Flags for Secondary Headache (SNOOP4E)
Systemic symptoms, illness, or condition (e.g., cancer, chills, fever, immunocompromise, infection, myalgias, night sweats, pregnancy or postpartum, weight loss) |
Neurologic symptoms or abnormal signs (e.g., confusion, diplopia, focal neurologic signs, impaired consciousness, meningismus, pulsatile tinnitus, seizures) |
Onset occurs with maximal intensity within minutes or “thunderclap” headache |
Older (age ≥ 50 years at onset) |
Progression (e.g., change in features, pattern, severity) |
Precipitated by Valsalva |
Postural aggravation |
Papilledema |
Exertional provocation |
FIGURE 1.
Algorithm for evaluation and treatment of headache.
Adapted from the U.S. Department of Veterans Affairs and U.S. Department of Defense. VA/DoD clinical practice guideline for the primary care management of headache. Accessed June 14, 2021. https://www.healthquality.va.gov/guidelines/Pain/headache/
FIGURE 1.
Algorithm for evaluation and treatment of headache.
Adapted from the U.S. Department of Veterans Affairs and U.S. Department of Defense. VA/DoD clinical practice guideline for the primary care management of headache. Accessed June 14, 2021. https://www.healthquality.va.gov/guidelines/Pain/headache/
Medication overuse headaches result from frequent use of acute headache medications. Medication overuse headaches often have a frequency between seven and 14 days per month and usually start after three months of frequent acute medication use. Using anxiolytics, analgesics, and sleep-inducing medications increases medication overuse headache risk. Celecoxib (Celebrex), prednisone, and specific medication withdrawal strategies have been proposed to wean overused medications, but none are superior to usual care.
Some nonpharmacologic treatments are effective for most headaches. Aerobic exercise and progressive strength training decrease headache frequency for numerous headache disorders. Mindfulness-based therapies may slightly reduce headache frequency for all headache types. Acupuncture yields small or inconsistent pain relief compared with sham acupuncture. Cognitive behavior therapy and biofeedback do not seem to be effective. Dietary food elimination trials and neuromodulation, including transcranial magnetic stimulation, transcranial direct current stimulation or pulsed radiofrequency, and sphenopalatine ganglion block have insufficient evidence.
There is no proven preventive medication for secondary headaches. Small studies suggest fluoxetine (Prozac) and venlafaxine slightly improve uncharacterized episodic headaches.
Primary Headaches
Tension-type, migraine, and cluster headaches are the most common primary headaches. Primary headaches are differentiated by clinical criteria from the International Classification of Headache Disorders, third
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Michael J. Arnold, MD, contributing editor.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
Copyright © 2021 by the American Academy of Family Physicians.
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