Headaches or migraines
At your visit your provider will ask detailed questions about the location, duration, severity, onset, quality and triggers of the headache and whether it is new or different from previous episodes. They will ask about associated symptoms like nausea, vomiting, fever, visual changes, aura, weakness or numbness, and whether you have any medical problems or are taking medication. A physical exam with vital signs and a focused neurological and head‑and‑neck exam is performed – the doctor looks at the eyes, checks the temporal arteries, palpates the scalp and jaw, examines the neck and checks reflexes and balance. The goal is to determine if the headache is a benign primary headache (migraine, tension or cluster) or if there are ‘red flags’ that suggest a more serious cause. New onset after age 50, sudden ‘thunderclap’ onset, worsening pattern, focal neurologic signs, fever, immunosuppression or recent head trauma are all warning signs that prompt further testing.
For mild attacks, over‑the‑counter medicines such as non‑steroidal anti‑inflammatory drugs (NSAIDs) like ibuprofen or naproxen and combination analgesics that include acetaminophen, aspirin and caffeine are often enough. For moderate‑to‑severe migraine or when simple analgesics fail, doctors may prescribe triptan medications (sumatriptan, rizatriptan, etc.) that block pain pathways in the brain. Antiemetic drugs can ease nausea; opiates and barbiturates are avoided because they can lead to medication overuse and rebound headaches. To prevent frequent migraines, certain medicines may be taken daily: beta blockers (propranolol, timolol), the antidepressant amitriptyline, and anti‑seizure drugs such as divalproex/valproic acid or topiramate have strong evidence for reducing how often headaches occur. Preventive therapy is considered when a person has two or more disabling migraines a month or fails acute treatments and is generally started at low doses and titrated slowly.
Most primary headaches do not require blood tests. However, doctors may order a complete blood count and metabolic panel to screen for infection, anemia or metabolic problems, and thyroid tests if hypothyroidism or hyperthyroidism is suspected in people over 50 with new headaches, erythrocyte sedimentation rate (ESR) and C‑reactive protein (CRP) tests can help rule out giant cell arteritis. Pregnancy tests may be done before prescribing certain medications. If infection or bleeding is suspected, cerebrospinal fluid may be analyzed via lumbar puncture.
Brain imaging is not needed for typical migraine or tension‑type headaches. When red flags are present or the neurologic exam is abnormal, a non‑contrast CT scan is used to look for bleeding or stroke, and an MRI may be ordered for more detailed images or to view the posterior fossa. Lumbar puncture and cerebrospinal fluid analysis help diagnose bleeding, infection, tumors or intracranial pressure disorders when CT or MRI is normal but suspicion remains.
Seek medical attention right away if you have sudden, severe ‘thunderclap’ pain; a new headache after age 50; headaches that increase in frequency or intensity; fever, stiff neck or rash; confusion, vision loss, double vision, weakness or numbness; difficulty speaking; seizures; or if the headache follows a head injury. Also seek care for headaches with jaw pain or scalp tenderness (possible temporal arteritis), or if headaches worsen when you cough, sneeze or strain.
Your doctor may ask you to keep a headache diary and will review it at follow‑up visits to gauge how often headaches occur and how treatments are working. After starting preventive therapy, follow‑up visits usually occur every 6–12 weeks until control is achieved, then every 3–6 months. Seek earlier follow‑up if medications are not helping or if side effects develop.
Lifestyle changes can reduce headache frequency. Follow the SEEDS plan: keep a regular sleep schedule, exercise for 30–60 minutes three to five times a week, eat balanced meals regularly and stay hydrated, track headaches in a diary to identify triggers, and manage stress through relaxation, mindfulness, biofeedback or cognitive behavioral therapy. Avoid skipping meals or using too much caffeine; limit alcohol; maintain a healthy weight; and talk with your doctor if certain foods, hormones or weather changes seem to bring on headaches.
Your primary care provider can manage most headaches. Referral to a neurologist or headache specialist is recommended if headaches are frequent, disabling or atypical, or if you need advanced treatments such as injections or infusions. An ophthalmologist may evaluate vision problems; physical or occupational therapists can teach posture and muscle relaxation techniques; a psychologist can help with stress management; and a dietitian can advise on food triggers. If giant cell arteritis is suspected, rheumatology may be consulted for biopsy and treatment.