Headache

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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
  • No similar headache in past
  • Age >50yr
  • Occipitonuchal HA
  • Visual disturbances
  • Exertional or postcoital
  • Family history of SAH or cerebral aneurysm
  • 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

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
    • 50% of patients with pneumococcal meningitis have evidence of pneumonia on CXR

Management

Non-specific Headache

Treat specific headache type, if known

  • 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L normal saline IV bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative metoclopramide 10 mg IV[5] (diphenhydramine addition shows no clinical benifit[6])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 30 mg IV
    • Lower doses are shown to be just as effective[7]
  • Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[8]
  • Avoid opioid medications if possible

Other 2nd and 3rd Line Medications

  • Magnesium 1 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[9]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes[10]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[11]
    • 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[12]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[13][14]
    • While less extrapyramidal symptoms than typical antipsychotics, beware QT prolongation
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[15]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[16]
  • 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[17]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[18][19][20]
    • 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[21]
    • 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 migranosus

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. Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  6. 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.
  7. 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.
  8. Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  9. Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  10. Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  11. Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  12. 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.
  13. Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  14. Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  15. Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  16. 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.
  17. 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.
  18. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  19. Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  20. 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.
  21. Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.