Headache
David Ng
Epidemiology of Headache
The prevalence of migraines is 10%–15%, and females are affected three times more than men.
Patients presenting with headache account for up to 4% of all emergency department (ED) visits.
Four percent of headaches have serious or secondary pathology.
0.5% of headaches have life-threatening pathology.
Twenty-five percent of women and 9% of men experience disabling migraines.
Disabling migraines cost 4–6 lost workdays a year, amounting to direct/indirect costs of 17 billion a year in the USA.
Pathophysiology of Headache
The brain parenchyma is insensate to pain.
Pain receptors originate in large cranial vessels, venous sinuses, proximal intra-cranial vessels, pia mater, and dura mater.
Serotonin (5-HT) receptors are the main focus of pain management as they are known to modulate peptide release and regulate cerebral vessels.
The anterior vessels are innervated by V1, while the posterior vessels are innervated by C2. Pain can be more generalized or referred to the associated dermatome.
Pathophysiology of primary headaches remains poorly understood.
Current theories of primary headache pathology include:
Hypersensitivity of nociception of myofascial tissue.
Cortical neuronal depression phenomena.
Abnormal vascular dilatation/inflammation.
Classification of Headache
Classified as either primary or secondary headache as per the International Headache Society (see Table 14.1).
Primary headache originates from the pain receptors.
Although potentially disabling, primary headaches are not life threatening.
Secondary headache is due to a specific pathology that stimulates the pain receptors.
Table 14.1: Primary and secondary headachesa
Secondary headache
Primary headache
Acute danger
Non-acute danger
Subarachnoid hemorrhage
Meningitis
Cerebral venous sinus thrombosis
Carotid/vertebral artery dissection
Pseudotumor cerebri
Glaucoma
Temporal arteritis
Eclampsia
CO poisoning
Brain tumora
Traumaa
Cervical stenosis of C2
Trigeminal neuralgia
HTN
Sinusitis
TMJ disorder
Post-lumbar puncture
Concussion
Medication overuse
Brain tumora
Traumaa
Tension
Migraine
Cluster
aDanger is dependent on degree of increased intracranial pressure, shift/effect on intracranial structures due to hemorrhage/mass effect.
It is important to identify which ones are life threatening to the patient.
Goals in the Emergency Department
Want to rule out all life-threatening secondary causes of headache.
Key questions to consider on history:
Periodicity and how this particular episode evolved.
Associated features.
Behavior during headache.
Family history of migraines and aneurysms.
Current medications.
Social situation and stressors.
What the patient thinks.
Fundoscopy should be carried out on all patients with headache, along with a neurological exam.
Patients presenting with the following red flags should have emergency neuroimaging in the ED:
New onset headaches.
Thunderclap headache.
Headache with an atypical aura (lasting over an hour or with motor weakness).
Aura without headache in a patient who is migraine naïve.
New headache in a patient over the age of 50.
Progressively worsening headache.
Headaches that change with posture or other maneuvers that increase ICP.
New headache in a patient with HIV, cancer, or immunodeficiency.
Headache with fever.
Headache associated with focal neurological symptoms.
Response to therapy should not be an indicator of benign etiology.
Specific Management of Headache in the Emergency Department
Primary Headaches
See Chapter 10 on pharmacology of pain management for specific medications.
Tension Type
Recurrent episodes that last from hours to days.
Typically bilateral, non-pulsating headache with no associated features.
Specific treatment:
Ibuprofen 200–400 mg, acetaminophen 1 gm q4hr (grade A).
NSAIDs (Naproxen 375, diclofenac 25, ibuprofen 400 mg) have similar effect to each other.
Caffeine 65 mg PO maybe a useful adjunct, but will increase GI side effects/dizziness (grade B).
Ketorolac 60 mg IM for acute relief of moderate to severe headache (grade B).
There is no evidence/conflicting evidence for the use of triptans and muscle relaxants.
Avoid narcotic, hypnotic combinations due to increased use of overuse, rebound, tolerance/dependency (grade C).
Migraine Type
Recurrent attacks that last from 4 hours to 3 days, usually having one to two episodes per month.
Patients are asymptomatic between episodes.
Typically unilateral, throbbing associated with nausea, vomiting, photophobia (may or may not have aura).
Specific treatment:
Intravenous fluids and dark/quiet environment.
Avoidance of physical activity.
If mild, consider NSAIDs, acetaminophen (grade B).
If moderate or severe pain, consider triptans or dopamine antagonists, both have about 65–70% response rate (grade A).
IV dexamethasone 10–25 mg shows modest effect in decreasing relapse rate at 24–72 hours, NNT = 9 (grade A).
If recurrent or disabling, consider prophylactic treatment – beta-blockers, TCAs, SSRIs, anticonvulsants (grade A).
Avoid opioids because they have increased risk of rebound headache with return to ED compared to placebo.
Cluster Type
Short-lasting attacks (anywhere from 15 min to 3 hr), recurring frequently in bouts of 6–12 weeks in a year.
Typically, severe unilateral orbital, temporal pain lasting 15–180 minutes, associated with ipsilateral lacrimation, rhinorrhea, facial swelling, miosis, and ptosis.Related posts:
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