Headache in the Emergency Department: 13 Dangerous Causes

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Also: RCVS and PRES, especially pregnant/postpartum (who are also at particular risk for CVST and of course preeclampsia).

emergency clinicians do not rule in migraine or other benign causes of headache. unless the headache is congruent to an established pattern for that patient, the history and physical specifically targets these 13 conditions.

subarachnoid hemorrhage: family history, PCKD, known berry aneurysm, sudden and maximal intensity at onset, posterior location

intracerebral hemorrhage: trauma, coagulopathy, decreased level of consciousness, hypertension

CNS infection: fever, immunocompromise, CNS instrumentation, recent head/face infection, meningismus

increased intracranial pressure: slowly progressive, cancer history, worse in morning, worse with head in dependent position, papilledema

carbon monoxide toxicity: contacts with similar illness, locationality (worse at home or at work)

acute angle closure glaucoma: unilateral anterior location, precipitated by darkness, change in vision, red eye

temporal (giant cell) arteritis: elderly, temporal location, jaw claudication, shoulder girdle symptoms

cervical artery dissection: unilateral pain involving neck/face, trauma history

cerebral venous sinus thrombosis: thrombophilia, neurologic signs/symptoms in non-arterial distribution, eyelid edema, proptosis

hypertensive encephalopathy: altered mentation, marked hypertension, improves with antihypertensive therapy

ENT/dental infection: ear, sinus, dental findings

idiopathic intracranial hypertension: young overweight female, hormone use, vision changes

preeclampsia: late pregnancy or postpartum


Ottawa SAH Rule / ACEP Headache Clinical Policy, June 2019

1. Neck pain/stiffness

2. Age ≥40

3. Witnessed LOC

4. Onset during exertion

5. Thunderclap (peak intensity at onset)

6. Limited neck flexion on exam

If one or more features present, CT. If negative CT within 6 hours of onset and neuro exam normal, SAH ruled out. Otherwise CT angio or LP may be used as second test.

Oxygen for undifferentiated headache (and other treatments)

Cephalgia in ED responds to oxygen

– High-flow oxygen is commonly used for cluster headache. Might it work for all-comers with headache?

– This was a tiny randomized trial with three groups: 17 to high-flow oxygen for 15 minutes, 14 to high-flow air for 15 minutes, and 17 to nothing for 15 minutes prior to standard medical therapy. The oxygen group did far better with regard to time to relief, 40 vs. 110 or 120 minutes; length of stay was 57 vs. 210 or 180 minutes; CT was less; less pharmacotherapy was needed, 29% (oxygen group) vs. mid-80s% in the other groups; and headache intensity was much less using visual analog scale.

– Assuming no contraindications to high-flow oxygen, this small trial, if confirmed, could change the way we treat all headaches.

– Put high-flow oxygen on your next headache patient, and see if it works.

Veysman BD et al. Annals of Emergency Medicine, Volume 54, Issue 3, Pages S71-S71

Antimigraine efficacy has been well demonstrated in multiple high-quality clinical trials for chlorpromazine, metoclopramide, and prochlorperazine, and droperidol. In general, these medications are inexpensive, well tolerated, and at least as efficacious, if not more so, than any agent to which they have been compared. These medications should therefore be considered first-line therapy for acute migraine in the ED setting.

Of the four agents mentioned above, chlorpromazine has fallen out of favor because of profound orthostasis that may accompany administration of this medication. Of the remaining three agents, droperidol is probably the most effective, with 2-hour headache relief rates approaching 100%. The ideal dose, as determined by a high-quality dose-finding study, is 2.5 mg. This medication is commonly used and exceedingly safe, but a recent FDA warning about QT prolongation has caused some clinicians to perform an EKG before medication administration.

Prochlorperazine administered in doses of 10 mg is also highly effective, although not quite as effective as droperidol. Metoclopramide is typically administered as a 10-mg intravenous dose but has been well tolerated and efficacious when administered as repeated successive doses of 20 mg.

Metoclopramide, prochlorperazine, and droperidol can all be accompanied by extrapyramidal symptoms, particularly akathisia, which often goes unrecognized. Prophylactic administration of diphenhydramine is a reasonable course of action, as are slower intravenous drip rates.

Metoclopramide has a favorable pregnancy rating and a long history of use for treatment of hyperemesis gravidarum. It is the most appropriate parenteral agent for treatment of acute migraine in pregnancy.

Emergency Medicine Clinics of North America Volume 27, Issue 1, February 2009, Pages 71-87