Core IM Podcast: 5 pearls on Headaches

October 18, 2017

Listen to CORE IM’s first 5 Pearls segment on Headaches!

Time Stamps

  1.   What are the indications for imaging for HA? (1:36)
  2.   What is your approach to abortive therapy for migraines? (4:45)
  3.   How do you diagnose medication overuse HA? (6:41)
  4.  What is your approach to migraine prophylaxis? (8:29)
  5. What are some evidence based nonpharmacological therapies for migraines?  (10:42)

Show notes

Pearl 1:

  1. Think about both patient characteristics and alarming headache qualities to determine if your patient’s headache requires imaging to look for secondary cause.
  2. Important patient characteristics are age and high-risk comorbities.
  3. Worrisome headache qualities include headache that awaken patient from sleep and constitutional symptoms.
  4. Remember that unless you’re looking for an acute bleed, MRI is the preferred imaging modality.

Pearl 2:

  1. NSAIDs are the first-line abortive therapy for both tension and migraine headaches.
  2. For moderate to severe migraines or when NSAIDs don’t work, triptans are useful abortive therapies.
  3. Don’t be scared to try multiple types of triptans if the first fails to help your patient.

Pearl 3:

  1. If you notice your patient’s headache changes from intermittent to a chronic, daily headache while using lots of abortive therapy medications, consider medication overuse headache.
  2. To avoid medical overuse headache, encourage your patient to limit triptans and NSAIDs to less than 2 times per week on average.

Pearl 4:

  1. If patients are getting migraines requiring abortive therapy more than 2x/week or have a medical overuse headache, think about adding migraine prophylaxis.
  2. Beta blockers like propranolol and anti-seizure meds like topiramate are the mainstay of migraine prophylaxis.

Pearl 5:

  1. There is strong evidence to support nonpharmacologic headache treatment, such as CBT, progressive muscle relaxation regular sleep and exercise!


  1. Loder, Elizabeth, et al. “Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question.” Headache: The Journal of Head and Face Pain 53.10 (2013): 1651-1659.
  2. Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: An evidence-based analysis. Ont Health Technol Assess Ser. 2010;10:1- 57.
  3. Detsky, Michael E., et al. “Does this patient with headache have a migraine or need neuroimaging?.” Jama 296.10 (2006): 1274-1283.
  4. Gilmore, Benjamin, and Magdalena Michael. “Treatment of acute migraine headache.” Am Fam Physician 83.3 (2011): 271-280.
  5. Munksgaard SB, Jensen RH. “Medication overuse headache.” Headache. 2014: 807-22.
  6. Pringsheim, Tamara, et al. “Canadian Headache Society guideline for migraine prophylaxis.” Can J Neurol Sci 39.2 Suppl 2 (2012): S1-59.
  7. Mauskop, Alexander. “Nonmedication, alternative, and complementary treatments for migraine.” CONTINUUM: Lifelong Learning in Neurology 18.4, Headache (2012): 796-806.
  8. Silberstein, S. D., et al. “Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.” Neurology 78.17 (2012): 1337-1345.