Diagnoses and Managementof Acute Headachein theEmergency Department

Case I: 40 yo. F-brought to the ER by EMS, c/o severe HA. Describes HA as pounding in nature, diffuse, sudden onset, associated with N/V X 3 over the last several hours. Also c/o dizziness & blurry vision.

PE: VSS-appears in moderate distress and remains recumbent on the examination table during the entire assessment. HEENT: PERRLA, EOMI but squints when testing pupillary response. Resists movement when asked to flex her neck and cries out when you attempt to assist her with neck flexion. Neuro exam: occasional slurring of speech and lethargy noted.

Remaining of the Physical Exam is nl.

Case II: 42 yo. F-presents to the ER stating that she is having a migraine and is requesting narcotics for pain relief. She has a long hx. of migraines and usually receives an IM narcotic and is discharged home. She would have talked to her FP for this but she’s out of town.

She was placed in urgent category by the triage RN because of stated degree of discomfort. She has received ergotamine and imitrex in the past w/out adequate response. She’s allergic to NSAIDs.

PE: Sitting in a dark room with polarized sunglasses. She’s asking for pain relief and wondering aloud why you will not give it to her.

Headache Is a Major Public Health Problem

. Up to 4% of ED Visits / 2% All Office Visits

. Over 20 Million Outpatient Visits

. 78 % of Women and 60% of Men Experienced at Least One Headache in the Year

. 36% of Women and 19% Men Suffered From Recurrent Headaches

Potentially Life Threatening Etiologies Characterize Patients Presenting to the Emergency Department With a Chief Complaint of a Severe Headachein <5% of the Cases

Goals of Headache Management in the Emergency Department

Primary Exclude Ominous Causes Provide Adequate Relief of PainSecondary Minimize Time Spent in the ED Establish Continuity of Care after discharge

History

Establishing a diagnoses when a patient

presents with a headache depends almost

entirely on taking an accurate patient

history and physical exam

Age of Onset

Benign syndromes usually begin before middle age

Ominous causes of headaches occur more frequently with advanced age

(>40 years old)

Duration of complaint

. Sudden onset: SAH or meningitis

. Gradual or chronic: Migraine, tension HA

Recently developed over several days,weeks or months

-New onset migraine or tension-type headache

-Increased Intracranial Pressure

-Temporal Arteritis

Headache Location

. helpful but nonspecific

Unilateral: Migraine, cluster

Bilateral/diffuse: Tension, Migraine

Associated Symptoms

. GI and Neurological symptoms most common example: eye pain, photophobia, N/V, syncope, fever, facial pain, jaw claudication, etc.

. Aggravating or relieving factors

. Family History: Migraine & SAH

. Other History MedicationMedications

Toxic exposures Toxic exposures Trauma Trauma Hypertension Hypertension HIVHIV

PHYSICAL EXAM

• Does the patient look ill?

• Vital signs: fever, BP

• HEENT & Neurological exams most important!

Fundoscopic exam Cranial nerves Mental Status Meningeal irritation Gait and reflexes

Tenderness on palpation

In Summary….

To what extend should each patient be evaluated?

Absolute clinical indications

Worst headache ever Onset associated with exertion Depressed cognition or neurologic deficit on exam Nuchal signs Deterioration during observation

Conservative approach acceptable in patients

Lack the above findings with normal VS Improvement during observation

Investigating Headache

Is any special investigation warranted?

When there is diagnostic difficulty or history suggests a serious disorder, investigation becomes obligatory!

CT-Scan

MRI

Lumbar Puncture

Blood Count/ESR

Headache ClassificationUser friendly IHS Classification

Primary Headaches Benign Headache disorders Migraine (with or without aura) Tension-type headaches Cluster headaches Drug rebound headaches-Medication overuse headache

Secondary Headaches Headaches that are symptoms of organic disease

Secondary Headaches Subarachnoid Hemorrhage Meningitis Temporal Arteritis Hypertension Glaucoma Trauma Non-meningitic Infections Pseudotumor Cerebri Metabolic Disorders Toxic Substances Space Occupying Lesions Sinusitis

Subarachnoid Hemorrhage

• sudden onset HA “unexpected clap of thunder”

• most common location is “occipitonuchal”

• excruciating pain,vomiting, obtundation

• Diagnosis: CT-Scan, LP (xanthochromia)

• Treatment: Seizure precautions Nimodipine 60 mg. orally Monitor BP Neurosurgical evaluation

Meningitis

• fever, stiff neck, mental status change

• headache worse with eye movement

• No papilledema or neurologic deficit seen

• Diagnosis: LP

• Treatment: start IV-Antibiotics immediately

Temporal Arteritis

• usually over 50 yrs old

• severe, throbbing temporal headache, jaw claudication, tender temporal artery

• loss of vision due to optic neuritis

• Dx: age >50, new onset HA, Temporal artery tenderness, elevated ESR (>50), (+) biopsy

• Treatment: Steroids/Neurology consult

Primary Headache Etiology????

Primary Headache Pathophysiology Hypotheses (specific cause unknown)

- Cortical spreading definition

- Migraine generator

- Vasodilation/inflammation

- Peripheral sensitization

- Genetic factors

- Others.…

International Headache Society Criteriafor MigraineMigraine Is an Episodic Recurrent HA lasting 4-72 Hours With:

Any 2 of these pain qualities:

. Unilateral pain . Throbbing pain . Pain worsened by

movement . Moderate or severe

pain

Any 1 of these associated symptoms:

.Neusea and/or vomiting

.Photophobia and phonophobia

Primary Headaches

Migraine Headache• Currently 28 million migraine sufferers age 12+ in USA -21 million females -7 million males

• Migraine prevalence peaks in the 25-55 age group -25% of women aged 18-49 suffer from migraine

• 1 in 4 households has at least 1 migraine sufferer

Migraine with Aura

• due to primary neuronal dysfunction

• corresponding decrease in blood flow to the area

• visual auras most common

“flashing lights or dark spots”• lasts 30 minutes to one hour-fully reversible

->60 minutes, r/o underlying ischemic/coagulopathic/embolic disorders• only seen in 15-20% of migraine patients

Cluster Headaches

Criteria for diagnoses: at least 5 attacksA. Severe unilateral orbital, supra-orbital and/or temporal pain

lasting 15 to 180 minutes

B. At least one of the following on the headache side;

. Conjuctival injection . Lacrimation . Facial/forehead sweating . Miosis . Nasal congestion . Ptosis . Eyelid edema . RhinorrheaC. Frequency: from one every other day to eight per day More common in males

Treatment: Oxygen, Triptans, Ergots, Indocin, Steroids

Chronic Tension HeadachesA. Average frequency of attacks >15 days/month for 6 months

B. At least two of the pain characteristics;

1. Pressing/tightening (non-pulsating) quality

2. Bilateral location

3. Not aggravated by routine physical activity

4. Mild/moderate severity

C. Both of the following;

1. No vomiting

2. No more than one of the following: N, photophobia, phonophobia

D. No evidence of organic disease

Treatment of Benign Headache in the Emergency Department

Parenteral Agents . Nonspecific analgesics: Narcotics . NSAIDs (Toradol)

Neuroleptics/antiemetics . Phenothiazines (Thorazine, Compazine) . Metoclopramide (Reglan)

Serotonin receptor agonists: Triptans, Dihydroergotamine

Narcotics

Widely used, esp. IM forms

Should be avoided for 3 reasons;

. Less effective, deals with pain, treating only a symptom

. Sedating, respiratory depression

. Abuse potential

Most useful in elderly and selected pregnant patients

Serotonin Receptor Agonists

. Receptor specific agonists that stimulate serotonin (5-HT1) receptors to reduce neurogenic inflammation

Dihydroergotamine (DHE) . Broader spectrum, affects serotoninergic, alpha-adrenergic and dopamine receptors

Sumatriptan: Imitrex

Others: Naratriptan(Amerge), almotriptan(Axert), rizatriptan(Maxalt), frovatriptan(Frova), eletriptan(Relpax), zolmitriptan(Zomig), etc.

D.H.E

• Offers primary therapy, not just pain relief

• Minimal side effects, mainly N/V

• No physical dependence; non-narcotic

• may be administered IV, IM, SQ and NS available

• Venoconstrictor-has no arterial vasoconstrictor effects

• General precautions; age over 60, DM and HTN

• other side effects: leg cramps, chest tightness

DHE

• IV/IM/SC: 0.25-1 mg., can be used 2-3x/day• Nasal Spray: 1 spray in each nostril (0.5 mg/spray) may repeat in 15 mins (4 sprays=2 mg) use no more than 2-3x/week, on separate days• Avoid use with macrolide antibiotics, in patients with ischemic heart dz, uncontrolled HTN• Other ergotamine medications; Ergotamine tartrate(ET): cafergot, Wigraine, etc. available in oral, suppositories, sublingual(ergostat) 2 tabs at onset, 1-2 q30-60 mins, max. 2-6/day no more than 2 days/week• cannot be used within 24 hours of triptan medications

Administration of D.H.E

Method IMethod I: Pretreat with 10 mg IV compazine over 2 mins

Wait app. 20 mins, administer 0.5-1.0 mg DHE-slow IVP over 2 minutes

Method IIMethod II: Draw 1 mg DHE and 2 ml of compazine in a single 3-ml syringe Administer through single venopuncture via 2 min. slow IVP

Method IIIMethod III: may use IM, slower onset of action

SUMATRIPTANSerotonin receptor agonist but differs from DHE

in 3 major respects;

1. Does not require use of an antiemetic agent, has antiemetic properties of its own

2. Available in a SC auto-injectable format containing a fixed 6-mg. dose and oral tablets

3. Has a relatively short half life of about 2 hours

Patient acceptance very high with SC, oral and NS

SUMATRIPTANSUMATRIPTAN

• SC dose: 6 mg. May repeat in one hour No more than 2 in 24 hours, limit 2 days/week

• Oral: 25-100 mg tabs…take at onset, may repeat in 2 hrs max. 100 mg/day

• Nasal Spray: 5 or 20 mg. 1 spray in each nostril may repeat in 2 hrs, max. 40 mg/24 hrs

Should not be used in patients with CV, cerebrovascular, severe HTN, severe hepatic impairment, angina or PVD.Do not take within 2 weeks of MAOI discontinuation

SUMATRIPTAN

• Excellent migraine medication for select patients

• Works rapidly, minimal nursing time and side effects• Recurrance of hadaches within 24 hrs-major objection to its use-may need repeat dose

• 2 deaths linked to this medication;

1. Woman with COPD 2. Patient w/CAD had MI 6 days after its use

• No ECG changes documented with use

• Pregnancy category C

DHE –vs-Sumatriptan

• Both are highly effective in aborting headaches

• DHE-IV requires treatment with anti-emetics, RN time

• Imitrex may require repeat treatment within 2 hours

• Side effects: similar

• Cost: Sumatriptan injection app. $35/dose

Nasal Spray: $ 35.00

DHE-45 1.0 mg injection app. $ 18.00/dose

Migranal NS: $ 43.00

Narcotic Seeking Patients

• Demanding behavior

• List of allergies

• Unusual history and presentation

• Difficult to deal with