Headache

Background

  • Headache accounts for ~2.2% of all ED visits[1]
  • The majority of these have a benign cause, but serious causes can be devastating, and a thorough H&P with an eye toward "red flag" symptoms is important in ED evaluation.

Headache Red Flags

Features

  • Sudden onset or accelerating pattern
  • Maximum intensity of pain at onset (i.e. "thunderclap")
  • Worse with valsalva
  • Worse in the morning or at night
  • No similar headache in past
  • Age >50 yr or <5 yr
  • Occipitonuchal headache
  • Visual disturbances
  • Exertional or postcoital
  • Family or personal history of SAH, cerebral aneurysm, or AVM
  • Focal neurologic signs
  • Diastolic BP >120
  • Papilledema
  • Jaw claudication

Clinical Context

Headache in setting of:

Clinical Features

History

  • Time to maximal onset
  • Location
    • Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy
    • Orbital - Optic neuritis, cavernous sinus thrombosis
    • Facial - Sinusitis, carotid artery dissection
  • Prior headache history

Physical Exam

  • Scalp and temporal artery palpation
  • Sinus tap / transillumination
  • EBQ: Jolt Test
  • Neuro exam

Jolt Test

  • Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
  • Although a 1991 study[2] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[3][4]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn

Differential Diagnosis

Evaluation of Headache

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Diagnosis

Laboratory Tests

Imaging

  • Consider non-contrast head CT in patients with:
    • Thunderclap headache
    • Worst headache of life
    • Different headache from usual
    • Meningeal signs
    • Headache + intractable vomiting
    • New-onset headache in pts with:
      • Age > 50yrs
      • Malignancy
      • HIV
      • Neurological deficits (other than migraine with aura)
    • Consider CXR
      • 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR

Management

  • Migraine
    • 1st line: Prochlorperazine (compazine) 10 mg IV (+/- Diphenhydramine)
      • Most effective therapy
    • 2nd line:
      • Metoclopramide (Reglan) 10 mg IV
      • DHE (Dihydroergotamine) 1 mg IV (often used with an antiemetic)
        • Contraindications: pregnancy, cardiovascular disease, HTN
      • Triptans
        • Contraindications: cardiovascular disease
    • Ketorolac
      • Lower doses are shown to be just as effective[5]
    • Dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge
  • Tension
    • NSAIDs

See Also

References

  1. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36. doi: 10.1016/j.annemergmed.2008.07.001.
  2. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
  3. Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
  4. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
  5. Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.