Rosen & Barkin's 5-Minute Emergency Medicine Consult (318 page)

FOLLOW-UP

• Headache secondary to suspected organic disease
  
• Intractable vomiting and dehydration
  
• Pain refractory to outpatient management
  
• Consider ICU admission:
  
  • Suspected symptomatic aneurysm
    
  • Acute subdural hematoma
    
  • SAH
    
  • Stroke
    
  • Increased ICP
    
  • Intracranial infection
    

• Most migraine, cluster, and tension headaches after pain relief
  
• Local or minor systemic infections (e.g., URI)
  

Patients with recurrent headaches should have follow-up with a neurologist or PCP.

• Chlorpromazine: 25–50 mg IM/IV (peds: 0.5–1 mg/kg/dose IM/IV/PO) q4–6h
  
• Dexamethasone: 10–24 mg IV once
  
• Dihydroergotamine: 1 mg IM/IV, repeat q1h; max. dose 3 mg
  
• Ergotamine: 2 mg PO/SL at onset, then 1 mg PO q30min; max. dose 10 mg/wk
  
• Ketorolac: 30–60 mg IM; 15–30 mg IV once, then 15–30 mg q6h (peds: 1 mg/kg IV q6h)
  
• Lidocaine 4%: 1 mL intranasal on same side as symptoms
  
• Metoclopramide: 5–10 mg IM/IV/PO q6–8h
  
• Morphine: 2.5–20 mg (peds: 0.1–0.2 mg/kg/dose) IM/IV/SQ q2–6h
  
• Prochlorperazine: 5–10 mg IM/IM/PO TID–QID; max. 40 mg/d
  
• Sumatriptan: 6 mg SQ, repeat in 1 hr, up to 12 mg/24h
  

• The sensitivity for detecting SAH on CT scan falls rapidly after 24 hr. LP remains essential for all patients with suspected SAH presenting after 6 hr of symptom onset.
  
• Neurology consultation should not delay urgent imaging in patients with high-risk features.
  
• Use dopamine antagonists with caution in patients with QT prolongation or electrolyte abnormalities. Use ergotamines and triptans carefully in patients with a documented history of CAD.
  
• Patients with chronic headaches and multiple visits benefit from consistent protocols for pain management; however, be alert to significant changes in their symptoms
  
• Do not wait for LP results to empirically treat cases of suspected meningitis.
  

• Edlow JA, Caplan LR, O’Brien K, et al. Diagnosis of acute neurological emergencies in pregnant and post-partum women.
  Lancet Neurol.
  2013;12:175–185.
  
• Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: Prospective cohort study.
  BMJ.
  2011;343:d4277.
  
• Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies.
  Emerg Med Int.
  2012;2012:949275.
  
• Swadron, SP. Pitfalls in the management of headache in the emergency department.
  Emerg Med Clin North Am.
  2010;28(1):127–147.
  

CODES

• 339.00 Cluster headache syndrome, unspecified
  
• 346.90 Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
  
• 784.0 Headache
  

BASICS

• Excruciatingly painful primary headache disorder
  
  • Infrequent cause of ED visits and affects only 0.1% of the population
    
• Often has abated by time of presentation
  
  • Attacks last between 15 and 180 min (75% last <60 min)
    
• More common in men (∼3:1)
  
• Onset usually between 30 and 50 yr of age
  
• Headaches occur in clusters lasting weeks to months followed by remission >1 mo
  
• Commonly occur 1–3 times per day during cluster period that lasts 2–3 mo
  
• Often occur during the same time of day
  
• Often occur during the same time of the year
  
  • Highest incidence in spring and fall
    
• Chronic cluster headache:
  
  • Remission <1 mo
    
  • Do not experience remission
    
  • 10% of patients
    
• May have many clinical and pathophysiologic similarities with migraine and variants
  
• Often follows a trigeminal nerve dermatome
  

A well-described physiologic reflex arc, the trigeminovascular reflex, potentiates the trigeminal pain and cranial autonomic features of cluster headache by positive feedback mechanisms.

DIAGNOSIS

• Unilateral pain (usually does not change sides between headaches)
  
• Sharp, stabbing, boring
  
• Acute onset and builds in intensity quickly with climax at 5–15 min
  
• Pain stops abruptly
  
• Often exhausted after episode
  
  • Location:
    
    • Eye
      
    • Temple
      
  • Radiation to:
    
    • Ear
      
    • Cheek
      
    • Jaw
      
    • Teeth (often have had extensive dental workup for pain in the past
      
    • Nose
      
    • Ipsilateral neck
      
• Episodes are often nocturnal
  
• Attacks are more likely after ingestion of alcohol, nitroglycerine, or histamine-containing compounds
  
• More likely in times of stress, prolonged strain, overwork, and upsetting emotional experiences
  
• No prodrome or aura
  

• Agitated, restless
  
• Prefer to stand and move around as opposed to migraine patients who prefer to lie quietly in a dark room
  
• Accompanying autonomic symptoms:
  
  • Ipsilateral to headache
    
    • Nasal congestion or rhinorrhea (or both)
      
    • Conjunctival injection or lacrimation (or both)
      
    • Facial flushing
      
    • Eyelid edema
      
    • Ptosis, miosis, or both (partial Horner's syndrome)
      
    • Sweating of face/forehead
      

• An accurate history and physical exam should confirm the diagnosis
  
• Life-threatening alternatives should be ruled out
  

• Lumbar puncture (if meningitis or subarachnoid hemorrhage is suspected)
  
• Erythrocyte sedimentation rate (ESR); if temporal arteritis is suspected
  

CT scan/MRI if suspect hemorrhage, tumor, etc.

• Migraine headache
  
• Trigeminal neuralgia
  
• Meningitis
  
• Temporal arteritis
  
• Intracerebral mass lesion
  
• Herpes zoster
  
• Intracerebral bleed
  
• Dental causes
  
• Orbital/ocular disease (acute glaucoma)
  
• Temporal mandibular joint syndrome
  

TREATMENT

• Recognize more severe life-threatening causes of headache
  
• Administration of oxygen by face mask may alleviate symptoms
  

• Rule out life-threatening causes of headache
  
• Administration of supplemental oxygen
  

• Ergots: DHE 0.5–1 mg IV; repeat in 1 hr if necessary
  
• Fentanyl: 2–3 μg/kg IV
  
• Morphine: 2–4 mg IV or IM, may repeat q10min
  
• NSAIDs: Ketorolac 15–30 mg IM or IV
  
• Oxygen: 100% via face mask
  
• Prochlorperazine: 10 mg IM or IV
  
• Somatostatin: 100 μg SQ
  
• Sumatriptan: 6 mg SC, may repeat in 1 hr (max. of 2 doses in 24 hr)
  
• Verapamil immediate release: Preventive drug of choice. Start at 80mg TID
  

• Oxygen: 12 L/min via nonrebreather mask for 15 min:
  
  • May increase to 15 L/min if refractory headache
    
• Sumatriptan
  
• DHE