754 Migdal et al.

Pain Medicine, 22(3), 2021, 754–758

doi: 10.1093/pm/pnaa429
Advance Access Publication Date:
Resident & Fellow Forum

Headache Made SIMPAL: A Simple Mnemonic for the Approach to

Headache Evaluation and Migraine Treatment
Christopher W. Migdal, MD,* Leon S. Moskatel, MD,† and Nathaniel M. Schuster , MD‡

*Department of Psychiatry, UC San Diego Health System, La Jolla, California; †Department of Neurology, Stanford Health Care, Palo Alto, California;
‡
Department of Anesthesiology, Center for Pain Medicine, UC San Diego Health System, La Jolla, California, USA

Correspondence to: Nathaniel M. Schuster, MD, UC San Diego Center for Pain Medicine, 9400 Campus Point Drive, MC 7328, La Jolla, CA
92037, USA. Tel: 952-237-8648; Fax: 877-991-7874; E-mail: nmschuster@ucsd.edu .

Funding sources: None.

Conflicts of interest: Dr. Migdal and Dr. Moskatel report no conflicts of interest. Dr. Schuster is a section co-editor for Pain Medicine, receives research
support from the Migraine Research Foundation, and is a member of the speaker’s bureau for Eli Lilly & Co.

Prior presentation: This article was based on a presentation, “Headache Diagnosis Made Simple,” delivered by Dr. Schuster at the American Academy
of Pain Medicine 36th Annual Meeting in National Harbor, Maryland, on March 1, 2020.

Literature estimates report that one in three patients pre- SNOOP Screener for Red Flags for Secondary Headaches
senting to multidisciplinary pain clinics has a chronic
headache disorder [1]. Given this, it is important for pain Stands for: Think:
S Systemic symptoms Infection
physicians to have an efficient approach to headache. We Secondary risk factors Metastasis
created a mnemonic—SIMPAL—as a straightforward yet N Neurological signs Mass lesion
thorough diagnostic and treatment checklist. Our ap- Stroke
proach emphasizes migraine because it is a diagnosis not Atlanto-axial instability
to be missed, given that it is highly prevalent and O Onset age >50 years Secondary causes in general
Temporal arteritis
treatable. O Onset thunderclap Subarachnoid hemorrhage
P Positional Intracranial hypertension
SIMPAL Mnemonic for Headache Evaluation and Migraine Intracranial hypotension
Treatment Papilledema Intracranial hypertension
Mass lesion
S Secondary headache warranting further evaluation? Prior headaches different Secondary causes in general
(SNOOP screener) Pregnancy Preeclampsia
I Identify the primary headache disorder Cerebral venous thrombosis
(ID-MigraineTM screener) Pituitary adenoma/apoplexy
M Medication overuse?
P Preventive/Prophylactic treatments
A Acute/Abortive treatments
L Lifestyle modifications The “SNOOP” mnemonic is useful for excluding dan-
gerous causes of headache [2].
S: Secondary headache warranting further When SNOOP features are present, physicians should
strongly consider further workup to rule out secondary
evaluation?
causes of headache [2]. After treatment of the underlying
Headache disorders are initially categorized into primary condition has been provided, sometimes pain physicians
and secondary headache disorders. Secondary headaches are called upon to provide symptomatic treatment of the
are caused by underlying conditions, and many are dan- remaining secondary headache disorder. Treating these
gerous; prompt recognition and treatment are necessary. secondary headaches can be difficult, as there is a paucity
 Headache Made SIMPAL 755

of evidence for the symptomatic treatment of secondary
headache disorders. A reasonable approach is to treat
these headaches according to presenting phenotype. For
example, preventive and acute migraine treatments can
be trialed for symptomatic treatment of a patient who,
Once a diagnosis of migraine is established, it is im-
portant to determine and classify whether the patient has
episodic or chronic migraine.
Episodic vs. Chronic Migraine

long after a remote subarachnoid hemorrhage, is having
headaches with associated migrainous features (such as
nausea, photophobia, and phonophobia).
I: Identify the Primary Headache Disorder
Once a secondary headache is considered less likely, the
focus shifts to determining the primary headache disorder
through the use of the ID-MigraineTM screener and the
International Classification of Headache Disorders
(ICDH-3) [3].
Patients coming to pain clinics for headache often pre-
sent with chronic daily headache, a descriptive term for
the presence of headaches at least 15 days per month for
longer than 3 months. In our experience, the long-
duration chronic daily headache differential diagnosis
taught by Bigal and Lipton [4] is most applicable in the
pain clinic, with the addition of cervicogenic headache
and occipital neuralgia—two diagnoses very familiar to
pain physicians.
Chronic Daily Headache Differential Diagnosis for Pain Clinic
1 Chronic migraine
2 Chronic tension-type headache
3 New daily persistent headache
4 Hemicrania continua (and the other trigeminal
autonomic cephalalgias)
5 Cervicogenic headache
6 Occipital neuralgia
Episodic migraine <15 headache or <8 migraine days per month
Chronic migraine 15 headache and 8 migraine days per month
Patients with chronic migraine, very importantly,
must be screened for medication overuse. Also,
onabotulinumtoxinA is approved by the U.S. Food and
Drug Administration for chronic migraine but not for ep-
isodic migraine, on the basis of the results of clinical tri-
als [6].
Chronic Tension-Type Headache (CTTH)
CTTH typically presents as a bilateral headache that is
present on most days and is featureless (without migrain-
ous or autonomic features). Medication overuse is very
common in chronic tension-type headache, and the only
treatment patients might need is “addition by sub-
traction,” i.e., reducing or stopping their overused medi-
cation. Patients may benefit from a tricyclic
antidepressant such as amitriptyline or nortriptyline.
New daily persistent headache (NDPH)
NDPH is defined as the sudden development of a head-
ache that persists continuously without moments of relief
for more than 3 months in the absence of a prior head-
ache history. It may be with or without migrainous fea-
tures. Unfortunately, this disorder can be very treatment
refractory, with no established, effective treatments.
Trigeminal Autonomic Cephalalgias (TACs)
TACs are strictly unilateral, side-locked headaches with
ipsilateral autonomic features, such as lacrimation, rhinor-
rhea, or conjunctival injection.

Chronic and Episodic Migraine Trigeminal Autonomic Cephalalgias (TACs)

Migraine is the third leading cause of disability in people TAC Diagnosis Duration Frequency Treatments
under age 50 worldwide [5], so identification and treat-
Hemicrania Continuous Continuous Completely indomethacin
ment are essential. ID-MigraineTM, a simple, three- continua responsive
question validated migraine screening tool that can be Cluster 15–180 min Every other Acute treatments,
easily used and has a sensitivity of 0.81 and specificity of headache day to including high-flow
0.75 if two of the three responses are positive: 8 times oxygen and
per day subcutaneous
During the past 3 months, did you have the following sumatriptan; preventive
with your headaches? treatments, including
galcanezumab and
1. nausea, verapamil. Oral steroid
2. photophobia, taper or occipital nerve
3. limited ability to work, study, or do what you need to do [3]. blocks with steroids
can be helpful.
These can be remembered by using the mnemonic PIN: Paroxysmal 2–30 min 5–40 Completely indomethacin
hemicrania per day responsive
1. Photophobia SUNCT/SUNA* 5 sec-4 min 3–200 Lamotrigine is first-line
2. Incapacitating per day treatment
3. Nausea
*SUNCT/SUNA indicates short-lasting unilateral neuralgiform headache
with conjunctival injection and tearing (SUNCT) / short-lasting unilateral
neuralgiform headache with cranial autonomic symptoms (SUNA).
756
Cervicogenic Headache
Cervicogenic headache stems from cervical musculoskel-
etal sources and is well known to pain providers.
Treatments include physical therapy, trigger point injec-
tions, and third occipital nerve and C3–4 cervical medial
branch radiofrequency ablation.
Occipital neuralgia
Occipital neuralgia presents as shooting or stabbing pain
in the distribution of the greater or lesser occipital nerves
and can be treated with neuropathic medications and oc-
cipital nerve blocks. A positive response to occipital
nerve blocks alone should not be interpreted as diagnos-
tic for occipital neuralgia, as numerous randomized, con-
trolled trials have shown that migraine responds to
occipital nerve blocks [7]. Evaluating for migraine in
these patients remains crucial, as correctly identifying the
presence of migraine unlocks a large armamentarium of
effective preventive and acute treatments.
Although cervicogenic headache and occipital neural-
gia are technically secondary headache syndromes, we
consider them here together with the primary headache
disorders because they are usually not dangerous.
However, readers should be aware of possible dangerous
causes of cervicogenic headache (such as Atlanto-axial
instability) and occipital neuralgia (such as infiltrative
lesions near the occiput).
M: Medication Overuse
Medication overuse headache (MOH) is likely very com-
mon and underrecognized in pain clinics, and it is likely a
strong contributor to headache chronification in patients
with chronic migraine and chronic tension-type head-
ache. One study found that 29% of patients in an inter-
disciplinary pain clinic met criteria for MOH [1]. The
thresholds for overuse are listed below.
Medication Overuse Criteria [8]
10 days Triptans, ergots, opioids, butalbital-containing
per month medications, and acetaminophen/aspirin/
R
caffeine (ExcedrinV [GlaxoSmithKline plc,
Brentford, United Kingdom])
15 days per Acetaminophen or nonsteroidal
month anti-inflammatory drugs (NSAIDs)
MOH should always be considered in patients with
chronic migraine and chronic tension-type headache.
When this diagnosis is suspected, tapering or discontinu-
ing the suspected overused medication is recommended.
About 50% of patients with chronic daily headache re-
turn to having episodic migraine or episodic tension-type
headache after stopping the overused medication [9].
Migdal et al.
PAL: Preventive Treatments, Acute
Treatments, Lifestyle Modifications
The next three sections discuss treatment of migraine,
which should include preventive treatments, acute treat-
ments, and lifestyle modifications (Figure 1).
P: Preventive Treatments
Preventive treatments should be considered in all patients
with chronic migraine and in patients with episodic mi-
graine who have 4 or more headache days per month.
Figure 1 can help guide your preventive treatment
choices. If two classes of oral preventive medication are
not tolerated or not successful for patients with chronic
migraine, PREEMPT protocol chemodenervation with
onabotulinumtoxinA can be initiated and performed ev-
ery 12 weeks; for patients with either episodic or chronic
migraine, calcitonin gene–related peptide (CGRP) mono-
clonal antibodies (erenumab, galcanezumab, fremanezu-
mab, eptinezumab) can be considered. Nutraceuticals
such as magnesium and riboflavin have evidence for mi-
graine prevention, as do psychological treatments, such
as biofeedback, cognitive-behavioral therapy, and
mindfulness-based stress reduction [10].
A: Acute Treatments
Acute treatments should be provided for almost all patients
with migraine. Figure 1 can help guide acute treatment
choices. Triptans are most effective when used within the
first 30 minutes of the migraine attack. Ergots and triptans
carry vasoconstriction concerns and are considered contra-
indicated in patients with vascular concerns. For patients
for whom triptans are contraindicated because of vascular
concerns, lasmiditan should be considered as a serotonin
receptor agonist that does not act on blood vessels. For
patients with chronic migraine with MOH, the CGRP
small-molecule antagonists (ubrogepant, rimegepant) may
be considered to help reduce use of the overused medica-
tion, as they are not believed to cause MOH.
Lifestyle Modifications for Migraine
Get sufficient and regular sleep
Eat three meals a day
Stay well hydrated
Exercise regularly
Avoid modifiable, identified risk factors (but we don’t recommend elimi-
nation or other diets)
If you consume caffeine, consume low doses at the same time every day
L: Lifestyle Modifications
Lifestyle modifications should be included in migraine
care. We recommend the following lifestyle modifica-
tions to patients.
Headache Made SIMPAL 757

Figure 1. A menu for treatments for episodic and chronic migraine. *Includes noninvasive supraorbital nerve stimulation (Cefaly
[Cefaly Technology, Gra ^ ce-Hollogne, Belgium]), vagus nerve stimulation (gammaCore [electroCore LLC, Basking Ridge, New
Jersey, USA]), single-pulse transcranial magnetic stimulation (sTMS mini [Aruene Corporation, Tustin, California, USA]), and re-
mote electrical neuromodulation (Nerivio [Theranica Bio-Electronics Ltd., Netanaya, Israel]), as well as implantable devices, which
are beyond the scope of this article. mo¼ month; APAP¼ acetaminophen; NSAIDs¼ nonsteroidal anti-inflammatory drugs; D2¼ do-
pamine-2 receptor antagonists (e.g., metoclopramide, prochlorperazine); AEDs¼ antiepileptics; VPA¼ valproic acid; ARBs¼ angio-
tensin II receptor blockers; TCAs¼ tricyclic antidepressants; CGRPs¼ calcitonin gene–related peptide-targeted treatments; Mg¼
magnesium; B2¼ vitamin B2 (riboflavin). The difference in the order of acute treatments for chronic migraine as compared with epi-
sodic migraine is reflective of the risk of medication overuse headache (MOH) with frequent use in patients with chronic migraine.
R
We do not recommend aspirin/APAP/caffeine (i.e., ExcedrinV) for acute treatment in patients with chronic migraine, given the risk
of MOH with its frequent use.

We reassure patients that migraine is not their fault,
that not all people with migraine have triggers, and some
triggers (such as weather changes) are not modifiable—
that’s where preventive and acute treatments come into
play.
Depressive and anxiety disorders are highly comorbid
with, can exacerbate, and can be exacerbated by mi-
graine. Identification of psychiatric comorbidity and ap-
propriate treatment or referral to mental health care
providers is essential in the management of migraine.
Conclusion
The SIMPAL approach to headache can be used to screen
for dangerous secondary causes of headache; identify
non-dangerous causes of headache, with a focus on mi-
graine; evaluate for medication overuse; and deliver pre-
ventive, acute, and lifestyle treatments to patients with
migraine.
Authors’ Contributions
Nathaniel M. Schuster, MD, conceptualized the manu-
script, made a significant contribution to manuscript de-
sign, revised the manuscript for important intellectual
content, and approved the final version to be published.
Christopher W. Migdal, MD, made a significant contri-
bution to manuscript design, drafted the manuscript, re-
vised the manuscript for intellectual content, and
approved the final version to be published. Leon S.
758
Moskatel, MD, made a significant contribution to manu-
script design, drafted the manuscript, revised the manu-
script for intellectual content and approved the final
version to be published.
Board Review Question:
1)A 32-year-old woman with a history of hypothyroid-
ism and insomnia presents to the pain clinic for head-
aches since adolescence. She describes the headaches as
“sharp and intense” and as radiating from the left frontal
region to the left occipital region, and they are associated
with concomitant nausea, photophobia, and phonopho-
bia. She denies visual aura. Her headaches can last up to
8 hours, and they subside when she goes to sleep. She gets
approximately 16 headache and migraine days per
month, at least half of which are associated with photo-
phobia, phonophobia, and nausea. She previously used
oxycodone for her headaches, but her primary care pro-
vider recently stopped prescribing her opioids, and she
presents asking for a refill on her oxycodone. She denies
ever taking any daily medications other than levothyrox-
ine. Neurological exam is unremarkable and symmetric,
and the SNOOP screener is negative for red flags for sec-
ondary headache.
Which of the following are the most appropriate treat-
ments for this patient’s headache?
A. OnabotulinumtoxinA and ibuprofen
B. Sumatriptan and amitriptyline
C. Propranolol and oxycodone
D. Topiramate and venlafaxine
E. Rizatriptan and acetaminophen
Answer: (B).
This patient’s diagnosis is chronic migraine without
aura with concern for MOH due to using oxycodone
>10 days per month. With 16 headache and migraine
days per month, both acute and preventive treatment are
indicated.
(A) OnabotulinumtoxinA is not yet indicated, as she
has not yet tried any oral preventive treatments. (C)
Propranolol is an effective preventive treatment, but oxy-
codone can cause medication overuse headache and non-
Migdal et al.
opioid treatments are recommended. (D) Topiramate
and venlafaxine are both effective preventive treatments,
but neither is an acute treatment. (E) Rizatriptan and
acetaminophen are both acute migraine treatments, but
neither is a preventive treatment. (B) Sumatripan and am-
itriptyline is the correct answer, as sumatriptan is an ef-
fective acute migraine treatment, and amitriptyline is an
effective preventive treatment. Amitriptyline may also
help her insomnia.
Lifestyle counseling should also be provided to her.
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