Approximately 2.1 million patients per year present to United States emergency departments with a primary headache disorder. For emergency clinicians, the responsibility is twofold: First, exclude causes of headaches that pose immediate threats to the life and welfare of patients. Second, provide safe, effective, and rapid treatment of symptoms, while facilitating discharge from the emergency department with appropriate follow-up. While emergency management focuses on identification and treatment of life-threatening causes of headache, such as subarachnoid hemorrhage or bacterial meningitis, there is a tendency to misdiagnose specific primary headache disorders and fail to provide consistent, effective treatments in accordance with published guidelines. These mistakes can be avoided by resisting the temptation to label patients with specific primary headache diagnoses and by adopting a consistent, reproducible strategy for treatment of primary headache disorders in the emergency department that is evidence-based and effective.
You arrive for your shift in the ED and are greeted by a trio of patients with a chief concern of headache. The first is a 10-year-old boy brought by his parents for the evaluation of moderate-intensity frontal headaches that have been going on for several months. The headaches occur in the morning, resolve by the afternoon, and are not changing in character or frequency. He has no other symptoms and appears very well on your exam. The parents are concerned that their child has a brain tumor and are requesting a head CT.
The second patient is a 46-year-old female with a history of migraine headaches who presents with a severe, constant pain that started suddenly while running. She admits this “feels different than my normal headaches.” On examination, she appears ill and is vomiting. Her neurologic examination demonstrates mild neck stiffness. She asks for a refill of her sumatriptan, which “always works for my headaches.”
The third patient arrives by ambulance. She is a 27-year-old “frequent flyer.” She describes her typical migraine headache, not controlled with home medications. Her vital signs and examination are unremarkable. You would like to treat her quickly and effectively, knowing that, if you do not, she will make the rest of your day difficult
Feeling your own head starting to pound, you take a deep breath, grab the charts, and start your day, hoping that you don’t become the fourth patient with a headache.
The prevalence of headaches is staggering. It is estimated that almost one-half of the world’s adult population suffers from a headache disorder. While the vast majority of headache patients do not visit the emergency department (ED) for care, headache remains the fifth most common chief complaint, comprising approximately 2% of all ED visits in the United States.1-5 Given an average cost of $1800 per patient visit, this translates to billions of dollars per year in healthcare costs.6 While emergency management focuses on identification and treatment of life-threatening causes of headache, such as subarachnoid hemorrhage (SAH) or bacterial meningitis, there is a tendency to misdiagnose specific primary headache disorders and fail to provide consistent, effective treatments in accordance with published guidelines.7,8
Headaches are commonly classified into 2 groups: (1) primary headache disorders, where the etiology is unknown, and (2) secondary headache disorders, where the headache is attributed to a specific underlying cause.9 (See Table 1.) While emergency medicine training focuses on the identification and management of dangerous secondary causes of headache, the vast majority of patients who present to the ED suffer from a primary headache disorder. As such, it is helpful to use evidence-based strategies to diagnose, manage, and treat these patients. This issue of Emergency Medicine Practice discusses the initial workup and management of patients with primary headache disorders, with special detail to classification and medication options. Common pitfalls associated with the care of the headache patient are also discussed. Finally, basic algorithms will be presented to aid the emergency clinician in the treatment and disposition of the next headache patient.
For more information on diagnosis and treatment of headache in the ED, see the September 2010 issue of EM Practice Guidelines Update, “Current Guidelines For Management Of Headache In the Emergency Department,” and the February 2010 issue of Pediatric Emergency Medicine Practice, “Pediatric Migraine Headache: An Evidence-Based Approach.”
The available literature on headache disorders is sizeable. A literature search was performed using PubMed online with the following search terms: emergency headache, emergency migraine, emergency tension headache, and migraine treatment. Approximately 2400 articles from 1960 to present were reviewed. The National Guideline Clearinghouse (www.guideline.gov) and the Cochrane Database of Systematic Reviews were searched with the term headache and included 7 and 15 review articles, respectively. Guidelines released by the American College of Emergency Physicians (ACEP) and the American Academy of Neurology (AAN) were also searched. The Canadian, French, and European neurology guidelines were also reviewed. To find additional primary literature, a search for headache and migraine was performed in the following emergency medicine journals: Annals of Emergency Medicine, the American Journal of Emergency Medicine, Academic Emergency Medicine, BMC Emergency Medicine, Canadian Journal of Emergency Medicine, Emergency Medicine Clinics of North America, European Journal of Emergency Medicine, Journal of Emergency Medicine, and Western Journal of Emergency Medicine. The bibliographies from these articles were examined to verify accurate representation from the literature.
Emergency clinicians must be careful not to anchor on prior headache diagnoses. The primary goal is to rule out dangerous causes of headaches, even in those who have a history of benign headaches. Patients with migraines or tension headaches can still suffer from meningitis, SAH, or other causes of serious or secondary headaches.
Given the common pain pathway of headaches, a patient’s response to medication should not be used to aid in diagnosis of the headache disorder. Many case reports and case series have demonstrated that SAH and pain from structural brain lesions respond to triptans, neuroleptics, and ergots.27-30
While some red flags—such as fever and focal neurological deficits—are apparent on examination, it is the emergency clinician’s job to evaluate all red-flag signs and symptoms. Specifically, history of HIV or cancer should lower the threshold for diagnostic imaging, given that secondary headaches can present with apparently benign symptoms.
Studies have demonstrated that it is difficult to assign a specific headache diagnosis in the emergency setting. Primary headache disorders have variable presentations and often require multiple similar headaches for diagnosis by ICHD-2 guidelines. Further, an incorrect diagnosis can mislabel a patient with a chronic headache disorder, leading to anchoring bias by future physicians.151
Repeated opioid use may precipitate chronic migraines and the phenomenon of the “frequent flyer” patient, who becomes dependent on increasing doses of opioids for headache treatment. With many other appropriate drug choices, we do not recommend opioids as monotherapy.152 If opioids are needed, we recommend them in combination with other medications and only in the acute setting.
Specialist consultants, whether inhospital or outpatient, can develop specific plans for the prevention of primary headaches as well as home treatment strategies to avoid ED visits. Primary headache patients with multiple visits to the ED should have specific and appropriate outpatient follow-up.
It is difficult to alleviate all pain in many patients suffering from primary headache disorders.153 We recommend talking with patients and setting appropriate expectations for controlling and managing pain, and working to provide appropriate follow-up and specific return precautions.
Many primary headache medications, although benign, can have uncomfortable side effects, including chest tightness and tingling for triptans and akathisia for neuroleptics. It is important to inform patients of these common side effects before giving medications. If not, the experience of the side effect may only serve to worsen their primary headache.
Neuroimaging is not indicated for patients with primary headache disorders. It is costly, is time-consuming, and carries risks of radiation. Once dangerous secondary causes of headache are excluded by history and physical examination, laboratory tests and neuroimaging are not indicated.34
Patients with primary headaches often have recurrence of their pain. In fact, studies have been unable to discover factors that reliably predict which ED headache patients will have recurrence of pain. This should not be seen as a medical error, but rather, a natural progression of the disease. It does, however, emphasize the importance of appropriate discharge instructions to prepare patients if their headache returns.149
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Amandeep Singh; William E. Soares
June 2, 2012