35 yo female with a past medical history of hypertension presents with two hours of headache that was gradual in onset but is now 10/10. Reports a sharp pulsating pain in the front portion of her head. She reports that she has had several prior headaches but none have ever been this bad. Denies any family medical history. She has tried Tylenol at home with little improvement in her symptoms. Denies fever or neck stiffness however she has been persistently nauseous and had two episodes of vomiting. On exam she is resting quietly in a darkened room. Cranial nerves are grossly intact and she demonstrates no focal neurologic complaint. The remainder of her exam is unremarkable.
By the end of this module, the student will be able to:
- Understand the difference between primary and secondary headache disorders
- List the emergent differential diagnosis of headache
- Understand the “Red Flag” symptoms for headache
- Explain the importance of a complete neurological exam in the evaluation of all headache patients
- Recognize the causes of secondary headaches
- Describe treatment regimens for primary headache disorders
Headache is a common Emergency Department complaint. The causes of headache can range from benign to life threatening and these patients can deteriorate quickly, which makes thorough evaluation of these patients critical. Nearly 47% of adults report headaches at some time in their life and there are approx. 2.1 million ED visits per (2-4% of ED visits). While the differential for headache is large, a systematic approach to history and physical exam will allow for effective evaluation of these patients and determination of necessary diagnostic testing and therapeutic interventions.
Initial Actions and Primary Survey
As with all patients presenting to the Emergency Department, assessing ABCs is the first priority. The majority of patients presenting to the ED with headache will not require immediate intervention of airway, breathing or circulation.
Primary survey should include a brief assessment for gross neurological function and an assessment of mental status. Use of the GCS coma scale can be an effective tool as this can be a measurement over time during re-evaluation. Patients with headache and abnormal mental status may require immediate intervention. Primary survey should also assess for signs or symptoms of CNS infection with sepsis. Additionally, all patients presenting with headache following trauma should undergo full trauma assessment with cervical spine immobilization.
These patients will require frequent revaluation of their neurologic state and mental status, as well as the effectiveness of any interventions.
Patients with headache can present with a wide variety of complaints, associated symptoms, varying levels of pain and duration of symptoms. Obtaining a thorough history is crucial to differentiate causes of headache. Seek to understand the circumstances of the onset of the pain. Below are some key historical features that should be obtained during the history portion of the encounter.
- Was the headache sudden or gradual onset?
- Associated with activity/exertion or at rest?
- Aggravating or alleviating factors?
- Family history of headaches or vascular abnormalities?
- Associated symptoms may include: fever, neck pain/stiffness, photophobia, extremity or facial numbness/weakness, vision changes, speech or gait changes, nausea/vomiting
There are several high risk clinical features or “Red Flag Symptoms”. Positive findings in any of these should prompt a more detailed evaluation.
- New onset
- Neurological findings
- Sudden onset or worst at onset
- Fever or immune compromise (HIV/AIDS, Cancer)
- Progressive headache
- Jaw claudication, muscle aches, temporal artery pain
- Multiple patients with headache (CO toxicity)
- Pregnancy or post pregnancy
- Clotting disorder (primary or acquired)
- Eye pain
- Cervical Manipulation with facial pain or sudden onset headache
- Dizziness with headache
Many patients will report a history of prior headaches and be able to explain whether and how their current headache is different from prior. Inquire about what treatments they have attempted at home, if any. Inquire if others in the home have similar symptoms or if they recently started using the heater or furnace, both of which suggest carbon monoxide poisoning.
A thorough neurological exam is essential for all patients with headache. Include testing of motor and sensory function, cranial nerves, reflexes, pronator drift, rapid alternating movements, finger-to-nose and heel-to-shin testing, Rhomberg test, gait assessment and mini mental status evaluation. Perform a complete pupillary and fundoscopic exam to assess for asymmetric pupils, findings suggestive of acute angle closure glaucoma (minimally reactive mid-dilated pupils with ciliary flush), or findings suggestive of increased intracranial pressure (papilledema or loss of spontaneous venous pulsations). In patients with possible temporal arteritis, assess for tenderness in the temporal area.
When assessing patients with headache, it is important to consider both the most common etiologies of headache, as well as the life-threatening etiologies of headache. Broadly, headaches can be classified into two general categories; primary and secondary
Of headache that are classified as primary, a large majority (nearly 90%) are migraine, tension or cluster headache. The exact pathophysiology of these types of headache is poorly understood.
Migraine headache are frequently episodic and may have preceding auras, visual disturbances, photophobia/phonophobia or scotomas (visual field defects). Many patients will report a history of similar headache and may report that the headache is similar to prior episodes. Occasionally patients will present with neurologic deficits. If these symptoms have never been present with prior migraines, assume they are new and consider the diagnosis of acute CVA.
Tension headaches are common and have a variety of presentations based on the age and sex of the patient. Tension-type headaches are more common in males, are bilateral and frequently radiate from the back, neck, shoulders to the top and sides of the cranium. Symptoms may be worse with stress, lack of sleep, position or movement. Tension headaches are generally gradual in onset and reach maximal intensity over hours to days. Many patients report ineffective management with typical over-the-counter medications.
Cluster headaches are typically located behind the eye and are generally exquisitely sharp and intense in pain. These patients may have neurologic signs related to the cranial nerves, such as lacrimation, ptosis, miosis or facial sweating. These are typically short-lived and limited in progression.
Other etiologies of primary headache are:
- Fever-associated headache
- Temporomandibular joint disease
- Trigeminal neuralgia
Secondary Headache or Emergent Headaches
Secondary headaches are the result of an intracranial process causing the development of the headache. Individuals will often have high risk features from their history. The rapid assessment and diagnosis of these conditions is crucial as there is a potential for deterioration of the patient. The differential for emergent headaches is extensive and some will be considered in other chapters (see links below).
- Subarachnoid hemorrhage
- Epidural hemorrhage
- Subdural hemorrhage
- Intracranial hemorrhage
- Stroke (although ischemic stroke uncommonly presents with headache)
- CNS infection (meningitis/encephalitis/abscess)
- CNS mass/increased intracranial pressure
- Idiopathic intracranial hypertension (aka pseudotumor cerebrii)
- Venous thrombosis
- Carbon monoxide poisoning
- Acute angle closure glaucoma
- Temporal arteritis
As with all testing done in the Emergency Department, diagnostic tests should be determined based off of history and physical exam findings. There are some general guidelines for evaluation of patients with headache.
Computed tomography (CT) imaging is often the initial imaging test of choice for evaluating headache in the ED. A CT head without contrast of the head is a quick method to evaluate for possibly emergent causes of a headache. Patients with suspected SAH, SDH, intraparenchymal hemorrhage or epidural hematoma should be evaluated with CT head for evidence of bleeding (which will show up brightly on a CT of the head if acute blood). A CT head with contrast is rarely used in the evaluation of headaches caused by potential intracranial bleeding as it can obscure the presence of blood. CT head imaging with contrast is used in patients whom required evaluation for headaches related vascular compromise, infection or space occupying lesion. The use of CT head imaging should be considered in patients who present with “Red Flag” symptoms, have new onset headache or changes in the nature of their headache.
Additional testing should correlate to the suspected diagnosis. For example, if meningitis/encephalitis is suspected, a lumbar puncture with associated cerebral spinal fluid studies would be indicated. Routine blood work (CBC, BMP etc.) are likely to be less useful in headache diagnosis unless an infectious source are suspected or the patient is on anticoagulants.
For patients with a history of headache that are presenting with typical headache features additional labs or imagine may be of low utility in diagnosis of headache. As a general guideline, if you have a high index of suspicion for an emergent cause of the headache, additional work-up is often required.
Treatment of headaches can also be broken down based on the final diagnosis. We will focus on the initial treatment options for primary headaches. Simply because the pain improved after medications does not mean that a benign process is present. Patients with emergent headaches may report improvement or resolution of their pain and symptoms with medication. A complete workup should still be considered. The stepwise approach to the treatment of headaches follows.
First line management is typically undertaken with oral analgesic agents. Oral medications are typically the fastest way to administer analgesia and are often effective. However, many patients will often have already attempted these medications prior to presenting to the Emergency Department. A majority of patients will require intravenous administration of medications to achieve a sufficient level of relief. A brief discussion of various classes of intravenous medications are provided.
Non-steroidal anti-inflammatories drugs (NSAIDs)
These include ibuprofen, naproxen, meloxicam and ketorolac. These medications interrupt the production of inflammatory and pain inducing prostaglandins. Ketorolac is typically administered in intramuscular (IM) or intravenous (IV) routes, with higher efficacy being achieved through the IV route. While not technically a NSAID, acetaminophen is a very effective medication for treatment. The mechanism of action for acetaminophen is not completely understood.
These medications are a widely utilized class of medications in treating headaches. Medications such as prochlorperazine (Compazine), metoclopramide (Reglan), haloperidol (Haldol) are common agents in the ED. These medications do carry the risk of developing extrapyramidal symptoms (EPS) including akathisia, acute dyskinesia, dystonic reactions and tardive dyskinesia. The co-administration of anti-cholinergic medications such as diphenhydramine (Benadryl) are used to manage extrapyramidal symptoms. Dopamine antagonists have greatest efficacy if they are administered through IV route. They can be administered in IM routes, however efficacy tends to decrease with this route. Oral administrations tend to have the lowest rates of efficacy in treating headaches.
Triptan are a class of medications are often used in managing migraine headaches. Medications like sumatriptan (Imitrex), rizatriptan (Maxalt) and zolmitriptan (Zolmig) are used commonly as outpatient treatments. These medications work through the antagonism of serotonin receptors in the brain. These medications are also known as abortive medications because when taken at the earliest sign of migraine onset, they can stop progression to a full migraine. These often are not utilized in the ED since many patients will have had ongoing headaches and may have already tried these at home.
Other medications that can be used in managing acute headache include steroids, anti-epileptic, narcotic medications and ergotamines. Dexamethasone (Decadron) can be effective in preventing recurrence of primary headaches. Narcotic medications can be used if other modalities have not been effective. These tend to be less effective, place patients at risk for rebound headaches and could lead to dependency issues. Sometimes patients with headaches from causes such as cluster headaches or persistent migraines need admission and intravenous medications such as high dose steroids (cluster headaches) or Depakote (persistent migraines) If headache is unable to be resolved, a neurology consult may be indicated for additional management.
For emergent headaches from some secondary cause, additional treatments will be indicated depending on the initial diagnosis. This will also be covered in the specified sections.
Pearls and Pitfalls
- Obtain a thorough history and physical examination to help determine the etiology of the headache
- Ask about “Red Flag” symptoms in any patient presenting with a headache
- Consider secondary causes of headache if there are any differences in the characteristics of the headache in patients with a previous history of a migraine or regular headaches
- Obtain non-contrast imaging of the head with a CT scan when secondary causes of headache are suspected
- Utilize first line headache medications for patients who present with a primary headache
- Consider admission for those patients with a primary headache whose symptoms to not resolve with typical headache medications
C3 - Headache. (n.d.). Retrieved from https://www.emrap.org/episode/c3headache/c3headache
Bajwa, Zahid H. “Evaluation of Headaches in Adults.” UpToDate, 26 Oct. 2018, https://www.uptodate.com/contents/diagnosis-of-delirium-and-confusional-states?search=delirium&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Harrigan M, Felix AG. Headache. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658§ionid=109413172. Accessed January 17, 2019.
Author: Christopher Fowler, DO, University of Arkansas for Medical Sciences, Little Rock AR
Editor: Matthew Tews, DO, MS, Medical College of Georgia at Augusta University
Last Updated: September, 2019