Scope and Target Population:
Patients age 12 years and older who present with headache.


Clinical Highlights and Recommendations:

• Headache is diagnosed by history and physical examination with limited need for imaging or laboratory tests.
  - Warning signs of possible disorder other than primary headache are:
  - Subacute and/or progressive headaches that worsen over time (months)
  - A new or different headache
  - Any headache of maximum severity at onset
  - Headache of new onset after age 50
  - Persistent headache precipitated by a Valsalva maneuver
  - Evidence such as fever, hypertension, myalgias, weight loss or scalp tenderness suggesting a systemic disorder
  - Presence of neurological signs that may suggest a secondary cause
  - Seizures
  
• Migraine-associated symptoms are often misdiagnosed as "sinus headache" by patients and providers. This has led to the underdiagnosis and treatment of migraine.
  
• Appropriate pharmacological or analgesic treatment of acute headache should generally not exceed more than two days per week on a regular basis. More treatment other than this may result in medication-overuse chronic daily headaches.
  
• Disability from headaches is an important issue for migraineurs.
  
• All patients should be considered for prophylactic therapy.
  
• Migraines occurring in association with menses and not responsive to standard cyclic prophylaxis may respond to hormonal prophylaxis with the use of estradiol patches or estrogen-containing contraceptives.
  
• Women who have migraines with aura should avoid use of estrogen-containing contraceptives. Headaches occurring during perimenopause or after menopause may respond to hormonal therapy.
  
• Most prophylactic medications should be started in a low dose and titrated to a therapeutic dose to minimize side effects and maintained at target dose for 8-12 weeks to obtain maximum efficacy.

Priority Aims:

1. Increase the accurate diagnosis of headaches.
   
2. Increase the functional status of those with migraine.
   
3. Increase the rate of treatment plans or adherence to plan for mild, moderate and severe headaches for migraineurs.
   
4. Reduce the use of opiates and barbiturates for the treatment of primary headache.
   
5. Increase education for patients with primary headache.
   
6. Increase appropriate prophylactic treatment based on headache type (i.e., migraine, tension-type, cluster, menstrual-associated migraine headache and chronic daily headache).
   
7. Increase appropriate acute and prophylactic treatment for migraineurs based on level of severity (i.e., mild, moderate or severe migraine).
   

Additional Background:
Migraine headaches affect an estimated 23 million Americans, with 11 million experiencing significant headache-related disabilities. Migraine headaches also have an economic impact through significant losses in productivity as well as through health care costs. Substantial scientific progress has been realized in recent years in abortive and prophylactic treatment of migraine headaches.