Diagnoses and Management
of
Acute Headache
in the
Emergency Department
Case I: 40 yo. F-brought to the ER by EMS, c/o severe
HA. Describes HA as pounding in nature, diffuse, sudden
onset, associated with N/V X 3 over the last several
hours. Also c/o dizziness & blurry vision.
PE: VSS-appears in moderate distress and remains
recumbent on the examination table during the entire
assessment. HEENT: PERRLA, EOMI but squints when
testing pupillary response. Resists movement when asked
to flex her neck and cries out when you attempt to assist
her with neck flexion. Neuro exam: occasional slurring
of speech and lethargy noted.
Remaining of the Physical Exam is nl.
Case II: 42 yo. F-presents to the ER stating that she is
having a migraine and is requesting narcotics for pain
relief. She has a long hx. of migraines and usually
receives an IM narcotic and is discharged home. She
would have talked to her FP for this but she’s out of town.
She was placed in urgent category by the triage RN
because of stated degree of discomfort. She has received
ergotamine and imitrex in the past w/out adequate
response. She’s allergic to NSAIDs.
PE: Sitting in a dark room with polarized sunglasses.
She’s asking for pain relief and wondering aloud why you
will not give it to her.
Headache Is a Major Public Health
Problem
. Up to 4% of ED Visits / 2% All Office Visits
. Over 20 Million Outpatient Visits
. 78 % of Women and 60% of Men Experienced
at
Least One Headache in the Year
. 36% of Women and 19% Men Suffered From
Recurrent Headaches
Potentially Life Threatening Etiologies
Characterize Patients Presenting to the
Emergency Department With a Chief
Complaint of a Severe Headache
in <5% of the Cases
Goals of Headache Management in the
Emergency Department
Primary
Exclude Ominous Causes
Provide Adequate Relief of Pain
Secondary
Minimize Time Spent in the ED
Establish Continuity of Care
after discharge
History
Establishing a diagnoses when a patient
presents with a headache depends almost
entirely on taking an accurate patient
history and physical exam
Age of Onset
Benign syndromes usually begin
before middle age
Ominous causes of headaches occur more
frequently with advanced age
(>40 years old)
Duration of complaint
. Sudden onset: SAH or meningitis
. Gradual or chronic: Migraine, tension HA
Recently developed over several days,weeks or months
-New onset migraine or tension-type headache
-Increased Intracranial Pressure
-Temporal Arteritis
Headache Location
. helpful but nonspecific
Unilateral: Migraine, cluster
Bilateral/diffuse: Tension, Migraine
Associated Symptoms
. GI and Neurological symptoms most common
example: eye pain, photophobia, N/V, syncope, fever,
facial pain, jaw claudication, etc.
. Aggravating or relieving
factors
. Family History: Migraine & SAH
. Other History
Medications
Toxic exposures
Trauma
Hypertension
HIV
PHYSICAL EXAM
• Does the patient look ill?
• Vital signs: fever, BP
• HEENT & Neurological exams most important!
Fundoscopic exam
Cranial nerves
Mental Status
Meningeal irritation
Gait and reflexes
Tenderness on palpation
In Summary….
To what extend should each patient be evaluated?
Absolute clinical indications
Worst headache ever
Onset associated with exertion
Depressed cognition or neurologic deficit on exam
Nuchal signs
Deterioration during observation
Conservative approach acceptable in patients
Lack the above findings with normal VS
Improvement during observation
Investigating Headache
Is any special investigation warranted?
When there is diagnostic difficulty or history suggests a serious
disorder, investigation becomes obligatory!
CT-Scan
MRI
Lumbar Puncture
Blood Count/ESR
Headache Classification
User friendly IHS Classification
Primary Headaches
Benign Headache disorders
 Migraine (with or without aura)
 Tension-type headaches
 Cluster headaches
 Drug rebound headaches-Medication overuse headache
Secondary Headaches
Headaches that are symptoms of organic disease
Secondary Headaches
Subarachnoid Hemorrhage
Meningitis
Temporal Arteritis
Hypertension
Glaucoma
Trauma
Non-meningitic Infections
Pseudotumor Cerebri
Metabolic Disorders
Toxic Substances
Space Occupying Lesions
Sinusitis
Subarachnoid Hemorrhage
• sudden onset HA “unexpected clap of thunder”
• most common location is “occipitonuchal”
• excruciating pain,vomiting, obtundation
• Diagnosis: CT-Scan, LP (xanthochromia)
• Treatment: Seizure precautions
Nimodipine 60 mg. orally
Monitor BP
Neurosurgical evaluation
Meningitis
• fever, stiff neck, mental status change
• headache worse with eye movement
• No papilledema or neurologic deficit seen
• Diagnosis: LP
• Treatment: start IV-Antibiotics immediately
Temporal Arteritis
• usually over 50 yrs old
• severe, throbbing temporal headache, jaw
claudication, tender temporal artery
• loss of vision due to optic neuritis
• Dx: age >50, new onset HA, Temporal artery
tenderness, elevated ESR (>50), (+) biopsy
• Treatment: Steroids/Neurology consult
Primary Headache Etiology ????
Primary Headache
Hypotheses
(specific cause unknown) 
Pathophysiology
-Cortical spreading definition
-Migraine generator
-Vasodilation/inflammation
-Peripheral sensitization
-Genetic factors
-Others….
International Headache Society Criteria
for Migraine
Migraine Is an Episodic Recurrent HA
lasting 4-72 Hours With:
Any 2 of these pain
Any 1 of these
qualities:
associated
. Unilateral pain
symptoms:
. Throbbing pain .Neusea and/or vomiting
. Pain worsened by
.Photophobia and
movement
phonophobia
. Moderate or severe
pain
Primary Headaches
Migraine Headache
• Currently 28 million migraine sufferers age 12+ in USA
-21 million females
-7 million males
• Migraine prevalence peaks in the 25-55 age group
-25% of women aged 18-49 suffer from migraine
• 1 in 4 households has at least 1 migraine sufferer
Migraine with Aura
• due to primary neuronal dysfunction
• corresponding decrease in blood flow to the area
• visual auras most common
“flashing lights or dark spots”
• lasts 30 minutes to one hour-fully reversible
->60 minutes, r/o underlying
ischemic/coagulopathic/embolic disorders
• only seen in 15-20% of migraine patients
Cluster Headaches
Criteria for diagnoses: at least 5 attacks
A. Severe unilateral orbital, supra-orbital and/or temporal pain
lasting 15 to 180 minutes
B. At least one of the following on the headache side;
. Conjuctival injection
. Lacrimation
. Facial/forehead sweating
. Miosis
. Nasal congestion
. Ptosis
. Eyelid edema
. Rhinorrhea
C. Frequency: from one every other day to eight per day
More common in males
Treatment: Oxygen, Triptans, Ergots, Indocin, Steroids
Chronic Tension Headaches
A. Average frequency of attacks >15 days/month for 6 months
B. At least two of the pain characteristics;
1. Pressing/tightening (non-pulsating) quality
2. Bilateral location
3. Not aggravated by routine physical activity
4. Mild/moderate severity
C. Both of the following;
1. No vomiting
2. No more than one of the following: N, photophobia, phonophobia
D. No evidence of organic disease
Treatment of Benign Headache in the
Emergency Department
Parenteral Agents
. Nonspecific analgesics: Narcotics
. NSAIDs (Toradol)
Neuroleptics/antiemetics
. Phenothiazines (Thorazine, Compazine)
. Metoclopramide (Reglan)
Serotonin receptor agonists: Triptans, Dihydroergotamine
Narcotics
Widely used, esp. IM forms
Should be avoided for 3 reasons;
. Less effective, deals with pain, treating only a symptom
. Sedating, respiratory depression
. Abuse potential
Most useful in elderly and selected pregnant patients
Serotonin Receptor Agonists
. Receptor specific agonists that stimulate serotonin (5-HT1)
receptors to reduce neurogenic inflammation
Dihydroergotamine (DHE)
. Broader spectrum, affects serotoninergic,
alpha-adrenergic and dopamine receptors
Sumatriptan: Imitrex
Others: Naratriptan(Amerge), almotriptan(Axert),
rizatriptan(Maxalt), frovatriptan(Frova), eletriptan(Relpax),
zolmitriptan(Zomig), etc.
D.H.E
• Offers primary therapy, not just pain relief
• Minimal side effects, mainly N/V
• No physical dependence; non-narcotic
• may be administered IV, IM, SQ and NS available
• Venoconstrictor-has no arterial vasoconstrictor effects
• General precautions; age over 60, DM and HTN
• other side effects: leg cramps, chest tightness
DHE
• IV/IM/SC: 0.25-1 mg., can be used 2-3x/day
• Nasal Spray: 1 spray in each nostril (0.5 mg/spray)
may repeat in 15 mins (4 sprays=2 mg)
use no more than 2-3x/week, on separate days
• Avoid use with macrolide antibiotics, in patients with
ischemic heart dz, uncontrolled HTN
• Other ergotamine medications;
Ergotamine tartrate(ET): cafergot, Wigraine, etc.
available in oral, suppositories, sublingual(ergostat)
2 tabs at onset, 1-2 q30-60 mins, max. 2-6/day
no more than 2 days/week
• cannot be used within 24 hours of triptan medications
Administration of D.H.E
Method I: Pretreat with 10 mg IV compazine over 2 mins
Wait app. 20 mins, administer 0.5-1.0 mg
DHE-slow IVP over 2 minutes
Method II: Draw 1 mg DHE and 2 ml of compazine
in a single 3-ml syringe
Administer through single venopuncture
via 2 min. slow IVP
Method III: may use IM, slower onset of action
SUMATRIPTAN
Serotonin receptor agonist but differs from DHE
in 3 major respects;
1. Does not require use of an antiemetic agent,
has antiemetic properties of its own
2. Available in a SC auto-injectable format containing a
fixed 6-mg. dose and oral tablets
3. Has a relatively short half life of about 2 hours
Patient acceptance very high with SC, oral and NS
SUMATRIPTAN
• SC dose: 6 mg.
May repeat in one hour
No more than 2 in 24 hours, limit 2 days/week
• Oral: 25-100 mg tabs…take at onset, may repeat in 2 hrs
max. 100 mg/day
• Nasal Spray: 5 or 20 mg. 1 spray in each nostril
may repeat in 2 hrs, max. 40 mg/24 hrs
Should not be used in patients with CV, cerebrovascular,
severe HTN, severe hepatic impairment, angina or PVD.
Do not take within 2 weeks of MAOI discontinuation
SUMATRIPTAN
• Excellent migraine medication for select patients
• Works rapidly, minimal nursing time and side effects
• Recurrance of hadaches within 24 hrs-major objection
to its use-may need repeat dose
• 2 deaths linked to this medication;
1. Woman with COPD
2. Patient w/CAD had MI 6 days after its use
• No ECG changes documented with use
• Pregnancy category C
DHE –vs-Sumatriptan
• Both are highly effective in aborting headaches
• DHE-IV requires treatment with anti-emetics, RN time
• Imitrex may require repeat treatment within 2 hours
• Side effects: similar
• Cost: Sumatriptan injection app. $35/dose
Nasal Spray: $ 35.00
DHE-45 1.0 mg injection app. $ 18.00/dose
Migranal NS: $ 43.00
Narcotic Seeking Patients
• Demanding behavior
• List of allergies
• Unusual history and presentation
• Difficult to deal with