Headache for the NP Exam: Migraine vs Tension vs Cluster, Red Flags and Acute vs Preventive Treatment

Headache questions on the FNP and AGNP exams test two skills in order: excluding a dangerous secondary headache, then naming the primary headache and matching it to the right acute and preventive treatment. Migraine is a recurrent attack of 4 to 72 hours that is typically unilateral, pulsating and moderate to severe, with nausea or sensitivity to light and sound. Tension-type headache is bilateral, pressing and mild to moderate without nausea, and cluster headache is a short, severe, one-sided orbital pain with same-side autonomic signs. Any SNNOOP10 red flag moves the patient to imaging or referral before a primary diagnosis is made.

The diagnostic criteria come from the International Classification of Headache Disorders, 3rd edition (ICHD-3). Treatment follows the 2021 American Headache Society (AHS) consensus statement for acute care and the 2026 American Academy of Neurology (AAN) and AHS guideline for prevention.

Step 1: screen for red flags with SNNOOP10

The SNNOOP10 list (Do and colleagues, Neurology 2019) organizes the features that raise concern for a secondary headache. Each letter is a question to ask or an examination finding to look for.

Actions the exam expects:

• Thunderclap headache: emergency evaluation with noncontrast head CT; if the CT is negative and suspicion remains, lumbar puncture or vascular imaging follows. Never "prescribe a triptan and follow up."
• New headache after 50 with jaw claudication, scalp tenderness or visual symptoms: ESR and CRP, start glucocorticoids the same day if suspicion is high, and arrange temporal artery biopsy; delay risks permanent vision loss.
• Fever with neck stiffness or altered mental status: emergency department.
• Pregnant or postpartum patient with a new severe headache: check blood pressure and urine protein for preeclampsia.

Step 2: classify the primary headache with ICHD-3

When no red flag is present and the neurologic examination is normal, ICHD-3 criteria define the diagnosis and imaging is not indicated.

Migraine with aura

Migraine with aura requires at least 2 attacks with fully reversible visual, sensory, speech, motor, brainstem or retinal symptoms. At least three of six characteristics must apply, including gradual spread over 5 minutes or more, each aura symptom lasting 5 to 60 minutes, and headache within 60 minutes of the aura. An aura that is sudden, lasts longer than 60 minutes, or includes motor weakness should prompt evaluation for stroke or transient ischemic attack.

Migraine with aura has a practical consequence the exam likes: combined estrogen-progestin contraceptives are contraindicated because of the added stroke risk. A progestin-only or nonhormonal method is the correct choice.

Chronic migraine and medication overuse headache

Chronic migraine is headache on 15 or more days a month for more than 3 months, with migraine features on at least 8 of those days. Medication overuse headache, under ICHD-3, is headache on 15 or more days a month in a patient with a pre-existing headache disorder who has regularly overused acute medication for more than 3 months: 10 or more days a month of triptans, ergots, opioids or combination analgesics, or 15 or more days a month of simple analgesics such as acetaminophen or NSAIDs. The fix is limiting the overused drug and starting a preventive.

Step 3: acute treatment

Migraine

The 2021 AHS consensus statement keeps a stratified approach: match the drug to the attack severity and the patient's prior response.

Triptan cautions: contraindicated with ischemic heart disease, stroke or TIA, peripheral vascular disease, uncontrolled hypertension and hemiplegic or brainstem aura migraine, and not to be used within 24 hours of an ergot. Counsel about serotonin syndrome with SSRIs or SNRIs, although the risk is low. Lasmiditan causes dizziness and sedation, and patients should not drive for at least 8 hours after a dose. Gepants carry no vasoconstrictive effect, which is why they are the answer for the patient with cardiovascular disease.

Opioids and butalbital-containing products are not recommended for routine acute migraine treatment because they drive medication overuse and are less effective than migraine-specific drugs.

Tension-type headache

Acute care is a simple analgesic: acetaminophen, ibuprofen, naproxen or aspirin, with caffeine combinations as an option. Frequent or chronic tension-type headache calls for prevention, and amitriptyline is the most established drug option; nonpharmacologic care includes stress management, cognitive behavioral therapy and physical therapy.

Cluster headache

The 2016 AHS cluster guideline rates three acute treatments highly:

• High-flow oxygen: 100 percent oxygen at 12 to 15 L/min through a non-rebreather mask for about 15 minutes.
• Sumatriptan 6 mg subcutaneously.
• Zolmitriptan nasal spray.

Oral triptans and analgesics act too slowly. During a cluster period, verapamil is the standard preventive (obtain an ECG at baseline and with dose increases because of the risk of heart block), a short glucocorticoid course or a suboccipital steroid injection serves as a bridge, and galcanezumab has an indication for episodic cluster headache. New cluster headache warrants neurology referral and brain MRI to exclude a structural lesion, particularly in the pituitary region.

Step 4: migraine prevention

Who gets prevention

The 2026 AAN and AHS guideline recommends offering prevention to patients with 4 or more migraine days a month (or 4 or more moderate to severe headache days a month), to patients with substantial migraine-related disability, and to patients who meet criteria for medication overuse. Every patient with frequent attacks should be told that effective preventives exist.

What to choose

No single preventive is clearly superior. The guideline asks the provider to weigh efficacy, tolerability, long-term safety, cost and comorbidity through shared decision-making.

The 2024 AHS position statement made CGRP-targeting therapies a first-line option without a requirement to fail older drugs first; insurers may still require step therapy. For a patient who could become pregnant, avoid valproate and topiramate when possible, and maximize nonpharmacologic approaches.

How long and how to judge

Give a preventive at least 8 to 12 weeks at a tolerated dose before judging it, and 24 weeks for onabotulinumtoxinA. If the response is partial at 8 weeks, increase toward the maximum tolerated dose. Track attacks with a headache diary and a disability tool such as MIDAS or HIT-6. A good response is commonly framed as a 50 percent reduction in migraine days; after about 6 months of good control, discuss whether to taper.

Follow-up and referral

• Reassess acute treatment response after two or three attacks or about 4 to 8 weeks, and preventive response at 8 to 12 weeks.
• Ask about acute medication days at every visit to catch medication overuse.
• Refer to neurology for cluster headache, migraine with atypical or prolonged aura, chronic migraine not responding to two or more preventives, suspected medication overuse that cannot be managed in primary care, or diagnostic uncertainty.
• Send to the emergency department for thunderclap onset, fever with neck stiffness, new focal deficit, papilledema with visual loss, or suspected giant cell arteritis with visual symptoms.

Patient and family education

Teach patients to treat a migraine early in the attack, when the pain is still mild, and to keep a headache diary that records attack days, triggers and acute medication use. Explain the medication overuse limits in plain terms: triptans or combination products on fewer than 10 days a month, simple analgesics on fewer than 15. Regular sleep, meals, hydration and aerobic exercise reduce attack frequency; common triggers include sleep change, skipped meals, alcohol, stress and hormonal shifts. Patients on triptans should know the chest tightness side effect and the cardiac warning signs that mean stopping and seeking care. Family members of a patient with cluster headache should understand that agitation and pacing during an attack are typical, and that home oxygen is the fastest relief. Anyone with migraine should report a sudden worst headache, a headache with weakness or confusion, or a change in their usual pattern.

How the exam tests this

• The buried red flag. A long migraine-like history with one line about a new headache after age 50, a cancer history or onset during exertion. The answer is evaluation, not a triptan.
• Imaging a typical primary headache. A patient meeting migraine criteria with a normal examination does not need CT or MRI.
• Misreading behavior. Lying still in a dark room points to migraine; pacing and rocking points to cluster.
• Triptan in coronary disease. The answer switches to a gepant or lasmiditan.
• Estrogen-containing contraception in migraine with aura. Contraindicated.
• Daily analgesics as the plan for frequent headaches. That creates medication overuse; the answer adds prevention and limits acute drug days.
• Judging a preventive after 2 weeks. The guideline requires 8 to 12 weeks at a tolerated dose.
• Oral treatment for cluster attacks. Oxygen or subcutaneous sumatriptan is correct.
• Topiramate or valproate for a young woman planning pregnancy. Avoid; choose a safer option.

Practice question

A 34-year-old woman reports headaches on about 6 days a month for the past year. Each attack is left-sided, throbbing, lasts most of the day, and is accompanied by nausea and sensitivity to light. She misses work during attacks. Ibuprofen gives partial relief, and sumatriptan 100 mg gives good relief, which she uses on about 6 days a month. She has no aura. Her neurologic examination and fundi are normal. She uses a levonorgestrel intrauterine device and has no other medical conditions. Which of the following is the most appropriate next step?

• A. Order MRI of the brain with and without contrast
• B. Continue sumatriptan for attacks and offer a migraine preventive, with a headache diary and reassessment after 8 to 12 weeks
• C. Replace sumatriptan with butalbital-acetaminophen-caffeine
• D. Advise her to take ibuprofen daily to prevent attacks

Answer: B. She meets ICHD-3 criteria for migraine without aura, has no SNNOOP10 red flag and a normal examination, and has 6 migraine days a month with missed work, which meets the 2026 AAN and AHS threshold to offer prevention while she keeps an effective acute triptan. Option A is wrong because a typical migraine with a normal examination does not warrant imaging. Option C replaces an effective migraine-specific drug with a butalbital product that is not recommended for routine use and promotes medication overuse. Option D creates medication overuse headache, since simple analgesics on 15 or more days a month meet the ICHD-3 threshold.

Key points

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