Urgent Care Management of Migraine and Other Primary Headaches (Pain Management CME and Pharmacology CME)

Table of Contents

 

About This Issue

Urgent care presentation of headache is common, and clinicians need to be prepared to evaluate and manage primary headaches, as well as assess for more concerning presentations such as refractory migraine, secondary causes, or headache disorders. Appropriate management of headache can streamline care, improve patient outcomes, and prevent unnecessary referrals to the emergency department. In this issue, you will learn:

The most common types of primary headache disorders, which include tension-type headache, migraine, and cluster headache, as well as medication overuse headache, a secondary headache disorder;

The difference between episodic headache and chronic headache;

The importance of a focused history, physical examination (especially a neurological examination), and clinical decision rules related to imaging studies and disposition; and

Treatment goals and pharmaceutical options for various types of primary headache disorders, including nerve blocks.

CODING & CHARTING: Factors such as severity of the headache, vital signs and associated symptoms, and underlying medical conditions influence the level of documentation required. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Tension-Type Headache
   2. Migraine
   3. Cluster Headache
   4. Medication Overuse Headache
6. Differential Diagnosis
   1. Episodic Headaches
   2. Chronic Headaches
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
   3. Clinical Decision Rules
8. Diagnostic Studies
   1. Laboratory Studies
   2. Red Flags for Urgent Transfer
   3. Imaging Studies
9. Treatment
   1. Intravenous Antidopaminergic Antiemetics
   2. Ketorolac
   3. Dexamethasone
   4. Dihydroergotamine
   5. Triptans
   6. Novel Oral Migraine Medications
      1. 5-HT1F Receptor Agonist
      2. Anticalcitonin Gene-Related Peptide Medications
   7. Opioids
   8. Nerve Blocks
      1. Greater Occipital Nerve Block
      2. Sphenopalatine Ganglion Block
   9. Butalbital, Acetaminophen, and Caffeine
10. Special Populations
    1. Older Patients
    2. Pregnant Patients
    3. Patients With Cluster Headaches
       1. Nerve Blocks for Cluster Headache
       2. Other Treatments for Cluster Headaches
       3. Patients With Medication Overuse Headache
11. Controversies and Cutting Edge
    1. Development of Novel Drug Treatments
    2. Diagnosis of Headache Disorder
12. Disposition
13. Risk Management Pitfalls for Managing Primary Headaches in the Urgent Care Setting
14. Summary
15. Time- And Cost-Effective Strategies
16. Case Conclusions
17. KidBits: Urgent Care Management of Primary Headache in Children
    1. Urgent Care Evaluation
    2. Treatment
    3. Special Considerations
    4. Disposition
    5. References
18. Critical Appraisal of the Literature
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
    2. Problems Addressed
    3. Complexity of Data
    4. Risk of Patient Management
    5. Documentation Tips
20. Coding Challenge: Managing Primary Headache in Urgent Care
21. Clinical Pathway for Managing Primary Headaches in the Urgent Care
22. References

Abstract

Headache is a common presentation in urgent care. Urgent care clinicians must be prepared to evaluate and manage primary headaches, as well as rapidly assess for potentially life-threatening secondary causes that require prompt referral or transfer. This review outlines the pathology, diagnostic approach, and treatment options for migraines and other primary headaches, using the best available evidence. It covers novel medications, nerve blocks, and strategies to prevent postdrome recurrence. Headache disorders are discussed, including cluster headaches, medication overuse headaches, and chronic migraines, along with treatment options for these disorders in the urgent care setting.

Case Presentations

A 36-year-old woman presents with a pounding left-sided headache associated with nausea that has persisted for 12 hours…

• She reports having similar headaches about twice monthly, and though they usually resolve with sumatriptan, she typically visits the urgent care about once a year for refractory events.
• This headache began gradually 12 hours prior and, despite taking oral sumatriptan 100 mg, ibuprofen 800 mg, and acetaminophen 1000 mg, it has not improved.
• Her physical examination is unremarkable, including normal vital signs, a normal fundoscopic and visual field examination, and a normal neurologic examination. A point-of-care urine pregnancy test is negative.
• You administer metoclopramide 10 mg IV and ketorolac 15 mg IV, but she reports only minimal relief.
• You wonder what your best next treatment option is…

A 45-year-old man with a history of infrequent, episodic migraines presents with an unremitting headache for 1 week…

• He reports an average of 3 severe headaches per year since high school, and they usually resolve completely with 10 mg oral rizatriptan.
• For the past 5 months, in association with increased stress at work, he reports an increase in headache frequency. At first, they occurred about once per week and responded to ibuprofen, but over the last month, he has had headaches nearly every day.
• Initially, he was getting relief with a combination of 10 mg oral rizatriptan once daily and 800 mg ibuprofen twice daily, but now these medications are not working at all. His headaches are associated with photophobia and phonophobia, and they are preventing him from functioning at work.
• His medical history is unremarkable, and the review of systems is otherwise normal. His physical examination, including vital signs, ophthalmologic, and neurologic examinations are normal.
• You wonder what you can offer him in the urgent care that might help…

A 24-year-old man presents to the urgent care with a dull headache that wraps around his head…

• He has never had a headache before.
• He notes that the headache started yesterday and says he hasn’t tried anything at home for his pain yet. He says anytime he presses on his head, the pain gets worse.
• His examination is notable for a band-like distribution of the headache. He has no photophobia or phonophobia. He denies any fevers, vision changes, or vomiting.
• You administer 1000 mg PO acetaminophen, and 30 minutes later he reports marked improvement in his symptoms.
• You wonder if he requires any additional workup while he is in your urgent care…

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

9. * Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363(1):63-70. (Review) DOI: 10.1056/NEJMct0910887

18. * Edlow JA, Panagos PD, Godwin SA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-436. (Research support, non-United States government) DOI: 10.1016/j.annemergmed.2008.07.001

28. * Orr SL, Friedman BW, Christie S, et al. Management of adults with acute migraine in the emergency department: the American Headache Society evidence assessment of parenteral pharmacotherapies. Headache. 2016;56(6):911-940. (Review) DOI: 10.1111/head.12835

49. * Patel D, Yadav K, Taljaard M, et al. Effectiveness of peripheral nerve blocks for the treatment of primary headache disorders: a systematic review and meta-analysis. Ann Emerg Med. 2022;79(3):251-261. (Meta-analysis; 9 studies) DOI: 10.1016/j.annemergmed.2021.08.007

52. * Robbins MS, Starling AJ, Pringsheim TM, et al. Treatment of cluster headache: the American Headache Society evidence-based guidelines. Headache. 2016;56(7):1093-1106. (Review) DOI: 10.1111/head.12866

53. * Obermann M, Nagel S, Ose C, et al. Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurol. 2021;20(1):29-37. (Randomized controlled trial; 118 patients) DOI: 10.1016/S1474-4422(20)30363-X

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Keywords: headache, headache disorders, episodic headache, cluster headache, tension-type headache, migraine, chronic migraine, migraine with aura, migraine without aura, primary headache, secondary headache, postdrome headache, thunderclap headache, medication overuse headache, nerve block, greater occipital nerve block, sphenopalatine ganglion nerve block, International Classification of Headache Disorders, photophobia, nausea, SNNOOP10 Criteria