Emergency Department Guidelines
HEADACHE
HEADACHE
Any of:
Acute Confusion
Reduced GCS
Fever
Focal neurol. deficit
Immuncompromised
Recognize:
signs of
meningococcal
sepsis
and initiate
treatment &
infection control
RESUS
IV Line
Bloods
Culture (if fever)
yes
no
CA patient?
Projectile vomiting?
Clinical Signs
of Infection?
yes
yes
no
no
Senior help
Start Abx,
Consider Acyclovir
Arrange CT scan / LP
SOL?
Thunderclap ?
Sudden onset,
Worse ever
yes
SAH?
Infection?
CT Scan
no
Neurosurgical
opinion needed?
Other Red Flags:
Head Trauma (<3/12)
Pain worsening with:
- physical exertion
- Valsalva, cough
- posture
Neck stiffness
Pain wakening the Pt
Jaw claudication
no
yes
no
ADMIT
(MEDICS)
yes
Discuss w/t
Neurosurgeon
Transfer to
Neurosurgery
Secondary
headache?
SENIOR
review
Visual disturbance?
Eye examination yes
yes
Acute glaucoma?
Glaucoma susp?
no
Give:
Acetazolamid
500 mg IV
no
Unilateral?
no
yes
Clinical signs of
Temporal Arteritis
and elevated ESR?
no
yes
Start Prednisolon
40-60 mg PO
Version 1.0 (Feb 2013)
Review date: Feb 2015
Tension headache
Migraine
Functional headaches
Refer to
Ophtalmology
Primary headache
Cluster headache
Migraine
Analgesia (see notes),
Reassure
Discharge with follow up
Refer to MEDICS
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Emergency Department Guidelines
KEY POINTS:
This is a diagnostic guideline for adults presenting with acute headache
RED FLAGS:
Signs of possible neuro-infection or SOL (space occupying lesion) or SAH:
- Acute confusion or reduced GCS
- Fever
- New inset focal neurologic deficit
- Immune compromised patient
- CA patient
- Projectile vomiting
- Recent head trauma (within 3 months)
- Thunderclap headache (sudden onset, peak within 5 min)
- Worse then usual headache
- Postural headache
- Neck stiffness
- Jaw claudication
 ABCDE
 Bloods (cultures if infection is suspected)
 Initiate Abx and consider Acyclovir if infection is suspected
 CT scan
 LP (if neuroinfection or if SAH suspected after negative CT scan)
 Admit patient under Medics / transfer to neurosurgical intervention if app.
RED FLAG – Signs of possible Acute Angle Closure Glaucoma (AACG)
- Visual disturbance, halo
- Unilateral red eye
 AACG is a medical emergency
 Give Acetazolamide 500 mg IV
 Refer patient to Ophthalmology for emergency admission
SECONDARY HEADACHES
Headache attributed to an underlying pathological condition. Includes
infections, neoplastic, vascular or drug-induced origin.
 see guidance / protocol for
– Subarachnoid Haemorrhage (SAH)
– Meningitis / Meningococcal sepsis
– Temporal arteritis / Giant cell arteritis (NICE)
– Medication overuse headache (NICE)
– Functional headaches / Menstrual-related headache (NICE)
PRIMARY HEADACHES
Headache not associated with underlying pathology
- Tension type headache
- Migraine (with or without aura)
- Cluster headache
Version 1.0 (Feb 2013)
Review date: Feb 2015
Page 2 of 4
Emergency Department Guidelines
Migraine aura: (with or without headache)
- Fully reversible AND
- Gradual onset either alone or in succession over at least 5 min AND
- Last for 5 – 60 minutes
TYPICAL SYMPTOMS
ATYPICAL SYMPTOMS
Visual symptoms (positive
Motor weakness
or negative)
Double vision
Clinical signs Sensory (positive or
Unilateral visual symptoms
negative)
Poor balance
Speech disturbance
Decreased conscious level
ED Plan:
Observe
Senior review / CT scan
Diagnosis of the most common primary headaches
Feature
Tension-type
headache
Bilateral
Migraine
(with or without aura)
Unilateral or bilateral
Pain location
Pain quality
Pain
intensity
Effect on
activities
Pressing, tightening (nonpulsating)
Mild or moderate
Not aggravated by
routine activities of daily
living
None
Other
symptoms
30 minutes – continuous
Duration
Frequency of
headaches
DIAGNOSIS
ED
Management
< 15 days
per month
Episodic
tension
type
headache
≥ 15 days
per months
for more
than 3
months
Chronic
tension
type
headache
-Aspirin, Paracetamol,
NSAID
Version 1.0 (Feb 2013)
Review date: Feb 2015
Pulsating (throbbing or
banging - young adults
12-17 y)
Moderate or severe
Aggravated by or
causes avoidance of
routine activities
Sensitivity to light
Nausea / vomiting
Aura:
Symptoms can occur
with or without
headache and:
- are fully reversible
- develop over at
least 5 minutes
- last 5-60 min
4 – 72 hr in adults
1 – 72 hr in young (1217y)
< 15 days
≥ 15 days
per month
per
months for
more than
3 months
Episodic
Chronic
migraine
migraine
(with or
(with or
without
without
aura)
aura)
-NSAID, Paracetamol
-Sumatriptan (Imigran)
50 mg PO or Intranasal
+/- metoclopramide
Cluster headache
Unilateral (around the
eye / along the side of
head/face)
Variable (can be sharp,
boring, burning,
throbbing)
Severe or very severe
Restlessness or agitation
On the same side as the
headache:
- red / watery eye
- nasal congestion
- swollen eyelid
- forehead / facial
sweating
- myosis, ptosis
15 – 180 minutes
½ - 8 per
day with
remission
> 1 month
½ - 8 per
day without
remission
> 1 month
Episodic
Cluster
headache
Chronic
cluster
headache
-Oxygen (12-15L/min)
-Intranasal Sumatriptan
(Imigran Nasal Spray)
Page 3 of 4
Emergency Department Guidelines
Subject
Applies to
Date issued
Status
Version
Review date
Responsible
person
Authorised by
Related
documents
This policy lays out guidance in relation to Headache
All staff working in the ED at East Surrey Hospital
14 March 2013
Approved
1.0
February 2015
Dr J Webb, Lead Consultant in Emergency Medicine
Dr C Dioszeghy Consultant in EM / Guideline
Medical Division Management Board for Quality and Risk
(submission 11th February2013)
NICE Clinical Guideline 150 – Headaches – Diagnosis and
management of headaches in young people and adults –
issued September 2012 – www.nice.org
Duncan CW at al: Diagnosis and management of headache
in
adults:
summary
of
SIGN
guideline,
BMJ
2008;337:a2329
Documents
replaced
Version 1.0 (Feb 2013)
Review date: Feb 2015
Page 4 of 4