Headache Presentation
New or recurrent headache complaint
All Pathways
Family MedicineDiagnostic
Primary Headache Evaluation & Management (AHS/AAN)
Primary Headache Evaluation & Management (AHS/AAN): Headache Presentation → SNOOP Red Flags → Urgent Evaluation.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Warning SNOOP Red Flags
Require urgent evaluation
- Systemic symptoms: fever, weight loss, immunocompromised, cancer
- Neurologic signs: focal deficits, papilledema, altered mental status
- Onset: sudden 'thunderclap' (SAH until proven otherwise)
- Older: new headache after 50
- Pattern change: different from prior headaches
03Action Urgent Evaluation
Imaging and/or LP indicated
- CT head STAT if thunderclap or acute neuro changes
- CTA if SAH suspected and CT negative
- LP if meningitis suspected
- MRI for tumor, abscess, venous sinus thrombosis
04Decision Primary Headache Type
Classify based on features
- Migraine: unilateral, pulsatile, moderate-severe, N/V, photo/phonophobia
- Tension-type: bilateral, pressing, mild-moderate, no N/V
- Cluster: severe unilateral orbital/temporal, autonomic features, circadian pattern
05Action Migraine
Episodic or chronic (≥15 days/mo)
- ICHD-3 criteria: 4-72h duration, unilateral, pulsating, moderate-severe, aggravated by activity
- Associated: N/V, photophobia, phonophobia
- With aura: visual, sensory, or speech symptoms before headache
- Track frequency for prevention decisions
06Action Migraine Acute Treatment
Treat early in attack
- NSAIDs: ibuprofen 400-800mg, naproxen 500-750mg
- Triptans: sumatriptan 50-100mg PO or 6mg SQ, rizatriptan 10mg
- Gepants: rimegepant 75mg, ubrogepant 50-100mg
- Antiemetics: metoclopramide, prochlorperazine
- Avoid opioids, barbiturate combinations
07Decision Prevention Indicated?
Consider if ≥4 headache days/month
- ≥4 migraines/month
- Significant disability despite acute treatment
- Contraindications to acute meds
- Medication overuse headache
08Action Preventive Medications
Trial for 2-3 months at target dose
- Beta-blockers: propranolol 80-240mg
- Antidepressants: amitriptyline 25-150mg, venlafaxine
- Anticonvulsants: topiramate 50-100mg, valproate
- CGRP mAbs: erenumab, fremanezumab, galcanezumab (if 2+ failures)
- Botox: for chronic migraine (≥15 days/mo)
09Action Neurology Referral
For complex or refractory cases
- Diagnostic uncertainty
- Failure of 2+ preventive medications
- Chronic migraine requiring Botox
- Cluster headache
- Medication overuse headache refractory
10Action Tension-Type Headache
Most common primary headache
- Bilateral, pressing or tightening
- Mild-moderate intensity
- Not aggravated by physical activity
- No N/V (may have mild photophobia OR phonophobia)
- Often associated with stress, poor posture
11Action Tension-Type Treatment
Acute and preventive options
- Acute: acetaminophen, NSAIDs (avoid overuse)
- Stress management, physical therapy
- If chronic: amitriptyline 10-75mg
- Address contributing factors: posture, screen time, sleep
12Warning Medication Overuse Headache
Headache ≥15 days/mo with regular analgesic overuse
- Triptans/opioids: ≥10 days/month
- Simple analgesics: ≥15 days/month
- Treatment: withdraw offending meds, start prevention
- Bridge with steroids or DHE may help
- Path rejoins step 09Shared downstream outcome
13Action Cluster/TACs
Trigeminal autonomic cephalalgias
- Severe unilateral orbital/temporal pain
- Autonomic: lacrimation, rhinorrhea, ptosis, miosis
- Short attacks (15 min - 3h) with circadian pattern
- Refer to neurology for diagnosis confirmation
- High-flow O2 and triptans for acute attacks
Guideline Source
AHS/AAN Practice Guidelines for Headache
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Medication overuse headache management simplified
- CGRP inhibitor selection not detailed
- Cluster headache treatment abbreviated
- Does not address pediatric headache
- Neurology referral criteria simplified
Applicable Regions
USAUUKEU
AU: NICE migraine pathway aligns
UK: NICE headache guidelines CG150
US: AHS guidelines for migraine prevention and acute treatment
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Primary Headache Evaluation & Management (AHS/AAN)?
The Primary Headache Evaluation & Management (AHS/AAN) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on AHS/AAN Practice Guidelines for Headache.
What guideline is the Primary Headache Evaluation & Management (AHS/AAN) based on?
This algorithm is based on AHS/AAN Practice Guidelines for Headache (DOI: 10.1177/0333102419893).
What are the limitations of the Primary Headache Evaluation & Management (AHS/AAN)?
Known limitations include: Medication overuse headache management simplified; CGRP inhibitor selection not detailed; Cluster headache treatment abbreviated; Does not address pediatric headache; Neurology referral criteria simplified. Individual patient factors may require deviation from these recommendations.
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