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ER Treatment of Headache: Expect
the Obvious, Rule Out the Serious |
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BY DON SCHRADER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
When evaluating headache patients in the emergency department,
physicians should suspect the obvious but rule out the
unexpected and potentially serious, Dr. Merle Diamond said
February 19 at a headache course sponsored by the Diamond
Headache Clinic Foundation for Research and Education.
“The most likely diagnosis is acute cephalalgia or benign
headache,” said Dr. Diamond, associate director of the Diamond
Headache Clinic in Chicago. “However, physicians in the
emergency department have to exclude serious problems, such as
subarachnoid hemorrhage. In most cases, a thorough medical
history can rule out serious causes of headache or,
alternatively, reveal ‘red flags’ that require further
evaluation.”
Headache is a major source of emergency department visits, which
entail considerable resource utilization. Each year more than 2
million emergency department visits result from headache-related
complaints, making headache the fourth most common cause of
trips to a hospital emergency room, said Dr. Diamond.
One recent study showed that 14% of headache patients who
present to emergency rooms have neuroimaging, 5.5% had organic
pathology, and 2% had lumbar puncture, which was abnormal in 11%
of cases (Cephalalgia. 2006;26:684-690).
Another recent study involved 785 patients from two large
clinical trials of chronic daily headache (Headache.
2005;45:891-898). Baseline characteristics showed that almost a
fourth of the patients had visited an emergency department, and
82% of those had gone to an emergency department more than once,
seeking care for chronic headache.
“A diagnosis of acute cephalalgia or benign headache leads to
nonspecific treatment and recidivism,” said Dr. Diamond.
The time course of a headache can give an emergency physician
good clues to the source of a patient’s headache. Headaches with
shorter time courses tend to be secondary headaches. An
excruciatingly painful headache with a sudden onset can reflect
vascular pathology, such as subarachnoid hemorrhage. Survivors
of subarachnoid hemorrhage often describe the pain as the worst
headache ever encountered.
Headaches of an infectious origin may evolve and intensify over
several days. An inflammatory or neoplastic process can cause
headaches that have a time course of weeks or months.
In contrast, primary headaches have a history that spans many
months, if not years.
The red flags that Dr. Diamond mentioned have multiple forms and
characteristics, such as: first or worst headache ever; abrupt
onset; a fundamental change in a patient’s headache patterns;
cancer, HIV infection, and pregnancy; abnormal physical
examination; neurologic symptoms lasting for an hour or longer;
and headache onset associated with a seizure or syncope.
An emergency physician can look for a similarly varied list of
reassuring signs that a headache is not serious, including:
stable headache pattern; long-standing history of headache;
normal physical exam; and consistent triggers, such as hormonal
cycles or specific foods.
Dr. Diamond recited a three-step process for emergency
department management of headaches: “Rule out secondary headache
disorders. Then, make a diagnosis; benign headache is not a
diagnosis. Finally, treat the disorder.”
Diagnostic testing for a patient with headache should be guided
by the history and physical exam. Before ordering a neurologic
scan (CT or MRI), a physician should have a suspicion about a
particular underlying cause of headache. Examples include
suspicion of cerebellar infarct, acute signs of increased
intracranial pressure, blunt head trauma associated with
increased intracranial pressure, and penetrating head injury.
Migraine is notoriously difficult to treat in the emergency
department. Physicians and other emergency personnel might have
an underlying distrust of a patient’s motivations. In
particular, patients with migraine and coexisting tension-type
headache often are recidivists who are prone to narcotic and
ergot abuse, said Dr. Diamond.
Emergency department treatment of migraine varies greatly. In
one study involving centers representing managed care, academic
medicine, and community medicine, fewer than 20% of patients
received migraine-specific medications (Ann Emerg Med.
2003;41:90-97). Of the almost 500 patients involved in the
study, 42% had nonspecific diagnoses of benign headache and 58%
had migraine diagnoses. Meperidine was the drug most commonly
used to treat headache. When patients received antiemetics, the
agents were not antidopaminergic.
Treatment of migraine in the emergency department should
emphasize use of standard abortive therapies, nonsteroidal
anti-inflammatory drugs, and appropriate antiemetics. Narcotics
should be administered with caution.
“Narcotics might be an appropriate option when abortive therapy
fails, when a patient does not have a history of abuse or abuse
is unlikely, and when abortive therapy is contraindicated by
factors such as pregnancy or allergy,” said Dr. Diamond.
“Narcotic drugs are appropriate for rescue treatment. When
narcotics are given to patients, long-acting agents should be
given in appropriate doses.”
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