Headache

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This page is for adult patients. For pediatric patients, see: headache (peds)

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.
  • When red flags are excluded, may attempt to define a common primary headache syndrome, but this is not an ED priority

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

Physical Exam

  • Scalp and temporal artery palpation
  • Neuro exam
  • HEENT and dental exam
  • Evaluate for meningismus
  • Sinus tap / transillumination
  • EBQ: Jolt Test

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

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

Evaluation of Headache

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 patients with:
      • Age > 50yrs
      • Malignancy
      • HIV
      • Neurological deficits (other than migraine with aura)
  • Consider CXR
  • Can rule out SAH for thunderclap headache if non-contrast head CT is negative and obtained within 6 hours of symptom onset. If further testing is needed after a negative head CT, can consider CTA, which is sensitive at detecting aneurysms >3mm [5] versus LP based on shared decision making
  • Consider CTA head and neck for headaches associated with head/neck trauma or neuro deficits
  • Consider Brain MRI for red flag symptoms with a negative CT head
  • Consider MRV to evaluate for cerebral venous thrombosis for headache in the setting of hypercoagulability

Management

Non-specific Headache

If known, treat specific headache type; avoid opioid medications if at all possible

  • 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L IVF bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative metoclopramide 10 mg IV[6] (diphenhydramine addition shows no clinical benifit[7])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 10-30 mg IV (30-60mg IM)
    • Lower doses are shown to be just as effective[8]
  • Sumatriptan most effective within 6 hours of headache onset[9]
    • Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
    • 6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
    • OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
    • OR 1-2 sprays IN (may repeat after 2 hours)
    • Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
  • Dexamethasone to prevent recurrence 48-72 hours post-ED discharge, if history of migraines and/or recurrent headaches[10]
    • 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. [11]

Other 2nd and 3rd Line Options

  • Magnesium 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[12]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[13]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[14]
    • Perform EKG monitoring for patients at risk of QTc prolongation
    • Do not give to patients who take already multiple QT prolonging drugs
  • Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications[15]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[16][17]
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[18]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[19]
  • Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process[20]
  • Sphenopalatine ganglion block
    • Great for patients without an IV
    • 10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes [21]
  • Consider greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [22]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[23][24][25]
    • Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
    • Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
    • Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg[26]
    • Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
    • Average dosage required ~100-125 mg

Disposition

  • Outpatient referral to primary care or neurology for recurrent, recalcitrant headaches
  • Admission for status migrainosus or dangerous underlying etiology

See Also

External Links

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. ↑ Raam R, Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes, An Update. Emerg Med Clin North Am. 2021 Feb;39(1):67-85. doi: 10.1016/j.emc.2020.09.004. PMID: 33218663.
  6. ↑ Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  7. ↑ Friedman BW, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of EM. January 2016. 67(1):32-39.
  8. ↑ 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(6Patient 2):116S-121S.
  9. ↑ Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Diener HC. Cephalalgia. 1999 Jul; 19(6):581-8; discussion 542.
  10. ↑ Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  11. ↑ Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.
  12. ↑ Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  13. ↑ Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  14. ↑ Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  15. ↑ Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.
  16. ↑ Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  17. ↑ Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  18. ↑ Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  19. ↑ Sin B et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7.
  20. ↑ Mellick LB et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.
  21. ↑ https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  22. ↑ https://www.nuemblog.com/blog/occipital-nerve-block
  23. ↑ The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  24. ↑ Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  25. ↑ Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.
  26. ↑ Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
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