Assessment:

1. Characterization of Headache:
   • Patients should describe the headache in terms of duration, quality, and location of the pain.
   • Medication Profile: Essential to know all medications, especially those used previously for headache control, including the number of over-the-counter (OTC) medications taken monthly.
2. Targeted Physical Examination:
   • Important to rule out secondary headache pathologies and confirm history.
   • Typically, findings in primary headache disorders are within normal limits.
3. Key Physical Examination Focus:
   • Cardiopulmonary and Neurologic Assessment:
     • Funduscopic and Pupillary Assessment
     • Auscultation of the carotid and vertebral arteries.
     • Mental Status Examination
     • Palpation of the head, neck, and temporal arteries.
     • Evaluation for neck stiffness, focal weakness, sensory loss, and gait abnormalities.
     • Vital Signs
4. Problematic Findings Include:
   • Onset of headache after age 50 years.
   • Asymmetry of pupillary responses.
   • Decreased deep tendon reflexes.
   • Headache described as “the worst ever experienced”.
   • Personality change.
   • Onset of a new or different headache.
   • Headache that progressively worsens.
   • Papilledema (swelling of the optic disc).
   • Painful temporal arteries.

Diagnosis:

1. Diagnostic Testing Considerations:
   • Use tests if the diagnosis is unclear or if history/physical findings are concerning.
   • Blood Tests (usually not needed) but may include:
     • CBC to exclude anemia or infection.
     • ESR or CRP to exclude temporal arteritis.
     • Thyroid Function Tests to identify thyroid dysfunction.
   • Lyme Titer or Rheumatoid Factors may be indicated in specific situations.
2. Practice Guidelines:
   • Three Principles for Diagnostic Testing:
     1. Avoid testing if it won’t change management.
     2. Testing is not indicated if the patient’s likelihood of having an abnormality isn’t higher than the general population.
     3. Testing may be justified for patients excessively concerned about a serious cause of their headaches.
   • Neuroimaging should be considered when serious signs or symptoms are present, but it’s not needed if:
     • Headaches have been present for years.
     • No focal neurologic signs.
     • Headaches improve without the use of analgesics.

Treatment:

1. Nonpharmacological Measures:
   • Behavior Modification: Adjusting habits and lifestyle factors that contribute to headaches.
   • Biofeedback: Techniques to control physiological functions such as muscle tension.
   • Acupressure: Applying pressure to specific points on the body.
   • Management of Headache Triggers: Identifying and avoiding personal triggers.
   • Wellness Program: Emphasizing overall health, including regular sleep, hydration, and balanced nutrition.