Article - Emergency Treatment of Headache

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EMERGENCY TREATMENT OF HEADACHE

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Consultant: Merle L. Diamond, M.D., Associate Director, Diamond Headache

Clinic

Internal Medicine Department, Columbus Hospital, Chicago, Illinois

phone 1-800- HEADACH

INTRODUCTION

Headache is a frequent presenting complaint in the emergency department. The

occurrence of headache as the chief complaint on admission is between 0.36%

to 2.5% of patients. The incidence of headache with significant morbid or

fatal outcome is not frequent.Determining differential diagnosis of the

patient presenting with headache is essential in order to rule-out organic

disease. Appropriate treatment regimens can be instituted once diagnosis has

been established. In the Emergency Department (ED), relief of acute pain

must usually be addressed. Referring the patient for follow-up care and

preventing repeat ED visits and possible narcotic habituation are recurrent

problems for the emergency physician.

BACKGROUND INFORMATION

In order to adequately treat the patient presenting to the ED with headache

as the chief complaint, the emergency physician must be familiar with the

various categories of headache. For simplicity, the division of headaches

into three categories--- organic, vascular, and tension-type --- is very

useful. Multiple disease processes are included in the category of organic

headaches. In evaluating the headache patient, the emergency physician must

be aggressive in diagnosing the patient in order to rule out life

threatening illness. The emergency physician can be reassured that organic

causes of headache occur rarely {<1%}.

Between 4.5% to 20% of headache patients visiting the ED will be suffering

from vascular headaches. Referral for follow-up is essential in order to

prevent frequent repeat visits to the emergency department and dependence on

habituating analgesics. At the ED, tension-type (muscle contraction)

headache is the most prevalent diagnosis among these headache patients.

Narcotic analgesics must be avoided in these patients.

PATIENT EVALUATION

History and Physical Examination

All patients presenting to the emergency department with the complaint of

headache should be interviewed carefully regarding their headache history.

This history is an essential tool in establishing the diagnosis. Patients

presenting with recent onset headache or a change in the character of their

headache should be thoroughly evaluated for possible organic disease. If the

patient complains of the " worst headache of my life " with associated stiff

neck, possible nausea and vomiting, and focal neurological symptoms,

subarachnoid hemorrhage should be ruled-out. Conversely, the patient with an

extensive history of headaches who presents at the ED with a typical acute

headache that has been triggered by dietary indiscretion or is associated

with menses, and is accompanied with nausea, vomiting, and photophobia, can

probably be diagnosed with migraine.

During the history, certain factors should be identified. The time of onset

of this particular headache, character of the pain, severity, duration, and

any associated symptoms with this particular headache should be outlined.

The interviewer should determine if the patient has a prior history of

headache, and obtain information about the original onset of the headache,

as well as any previous tests and treatment. The patient should also be

questioned about a family history of headache, any exertional aspects to the

acute attacks, and current therapeutic regimens.

A physical and neurological examination must be completed. If the patient

relates a recent onset of headaches, or a change in character of the

headaches, the emergency physician should be alert to possible organic

pathology. The extent of the examination is dependent on the patient's

current status. During the evaluation, the fundi, neck, throat, and nose

should be examined.

DIAGNOSTIC EVALUATION

Diagnostic testing will not usually establish the diagnosis in the majority

of patients presenting to the ED with headache. The physical examination and

the headache history will facilitate the choice of which diagnostic tests

should be performed. In ordering diagnostic studies, the emergency physician

should consider the possibility that the patient will not seek follow-up

care.

A complete blood count should be performed if there is any suspicion of an

infection, or if a marked anemia is suspected (which could cause a

hypoxia-related vascular headache). Evaluation of renal function and

electrolytes should be obtained in patients who appear to be dehydrated due

to status migraine with associated vomiting. Blood chemistries should also

be performed on those patients consuming excessive amounts of prescribed or

over-the-counter analgesics.

CT scanning is particularly useful in patients with headache. Mill's group

have devised criteria for the indication of a high-yield CT scan. The CT

scan can rule-out suspected organic cause, and if indicated, an M.R.I.

should be obtained. Suspicion of elevated intracranial pressure due to focal

lesions should indicate the need for obtaining a CT scan and a careful eye

ground examination prior to performing a lumbar puncture, in order to

prevent a possible cerebellar herniation. A CT scan should also be obtained

on any hypertensive patient with a change in sensorium and focal

neurological symptoms in order to rule-out increased intracranial pressure

and intercerebral bleeding. In 75-90% of patients with subarachnoid

hemorrhage (SAH), the CAT scan will demonstrate the abnormality, depending

on the resolution of the scanner. The CT scan may also differentiate brain

abscesses and some tumors.

A lumbar puncture is an important diagnostic tool in the ED. If the

emergency physician suspects meningitis, a lumbar puncture should be

performed. In the presence of an SAH, xanthochomia or red blood cells will

be demonstrated in the spinal fluid expressed during the lumbar puncture.

The fluid will also reveal white blood cells as well as bacteria in the

patient with bacterial meningitis.. As previously stated, previously, the

suspected presence of a focal lesion will contraindicate the performance of

a lumbar puncture. Therefore, a CT scan must be obtained, prior to a lumbar

puncture, on all patients with suspected increased intracranial pressure.

A sedimentation rate by the Westergen method should be obtained on all

patients over the age of 50 who present with recent onset headache or a

change in the character of the headache, in order to rule-out temporal

arteritis. If the sedimentation rate is elevated, a temporal artery biopsy

should be scheduled as soon as possible, and treatment with corticosteroids

should be started promptly in order to prevent irreversible blindness.

MEDICAL MANAGEMENT

SUBARACHNOID HEMORRHAGE (SAH)

At the ED, the most dramatic presentation is probably the patient with SAH.

These patients typically present with a history absent of previous headache

complaints. The patient with a previous history of headaches will usually

not report any unusual features of the headache nor describe difficulties

with their therapeutic regimen. The emergency physician should be cognizant

that thunderclap headache may occur in patients with migraine or with an

SAH. Approximately 10% of all cerebrovascular accidents are related to the

presence of a SAH, and an approximately 50 percent mortality rate has been

reporteD. It should be noted that 50 percent of those patients who survive

the initial bleed but do not receive treatment, will die within the next two

weeks.

The clinical picture of the patient with SAH is a terrible headache, usually

described as " the worst ever " , with a typically acute onset. Associated

symptoms will often be reported related to increased intracranial pressure

including nausea, vomiting, meningismus, and focal neurological signs. A

transient loss of consciousness associated with the onset of bleeding may

also be noted. Vital signs should be monitored as an elevated blood pressure

may occur due to sympathetic hypersensitivity.

MENNIGITIS

The life threatening diagnosis of meningitis will more likely be confronted

by the emergency physician than the office based clinician. This serious

problem may occur in any age group. The diagnosis of meningitis is confirmed

by examination of the cerebral spinal fluid, which may show cloudy fluid

under raised pressure, white cells, elevated protein, decreased glucose, and

positive cultures with elevated antigen levels. The purpose of the lumbar

puncture is to determine which causative agent is responsible. Hemophilus

influenza is the most prevalent cause of meningitis in children, aged 2-5.

Older children and adolescents with meninigitis are more frequently infected

with Neisseria Meningitis. In older patients, the cause of their meningitis

is usually due to Steptococcal pneumonia. Patients receiving

immunosuppressive treatment are particularly susceptible to those as well as

other organisms.

The clinical picture of the patient with meningitis is typically a severe

global headache, throbbing in nature, and associated with nausea, vomiting,

photophobia, and stiff neck. In some patients, an alteration in the level of

consciousness may occur. Also, a rash may be manifested. A morbid outcome

can be prevented with early diagnosis and treatment with the appropriate

antibiotic.

TEMPORAL ARTERITIS

In treating patients with temporal arteritis, early diagnosis and management

are essential and the emergency physician should be conversant with the

clinical picture of this disorder. Headache is the most common presenting

complaint. The typical patient has been previously asymptomatic, is over age

50, with the headache being recent in onset. The female to male ratio is

2:1. Associated systemic symptoms include weight loss, night sweats, low

grade fever, aching of joints, and jaw claudication. Polymyalgia rheumaica

is the medical terminology used to describe this cluster of symptoms.

The patient will complain of head pains or headache usually localized to the

affected scalp vessels. Another characteristic symptom is pain in the jaw

muscles on chewing. On examination, the area around the temporal artery is

usually tender to touch and the skin may appear red. The involved arteries

will dictate which physical signs will be present.

The absolute necessity for early diagnosis and treatment should not be

underestimated. Vision is lost in one or both eyes in 50 percent of

untreated cases. This condition can be easily ruled-out through the use of

the sedimentation rate. A sedimentation rate over 40 mm/hr indicates the

need for a temporal artery biopsy. Corticosteroid treatment can be initiated

during the interim while awaiting the temporal artery biopsy, if temporal

arteritis is suspected. The corticosteroid therapy may need to be continued

for several years, with follow-up sedimentation rates performed at regular

intervals.

TUMOR & BRAIN ABSCESSES

Inflammation, traction, and displacement or distention of the pain-sensitive

structures of the cranium will cause the headache due to intracranial

sources. The term " traction headache " describes the typical source of the

displacement. A rapidly expanding lesion, which produces traction on the

pain-sensitive areas of the head, will produce a headache which is a

cardinal sign of a brain tumor. Headache is a frequent manifestation of

increased intracranial pressure. If the tumor is slow growing, the headache

is usually mild and transient. This headache is easily relieved by

over-the-counter analgesics, and the patient will rarely visit an ED.

The morbid outcome of these traction headaches should alert the emergency

physician to the generalizations regarding headache due to brain tumor. The

patient with headache due to a brain tumor will often describe the pain as

deep, aching, steady, dull and rarely throbbing. This headache can, at

times, be severe, but is not typically as intense as migraine.

Over-the-counter analgesics and ice packs often relieve the pain.

Eventually, the headache may become progressive due to enlargement of the

mass and resultant surrounding cerebral edema. Increases in intracranial

pressure, due to Valsalva, exertion, or other maneuvers, may exacerbate the

pain. Focal signs may occur in patients with a mass lesion, depending on

which area of the brain is involved. Signs of increased elevation in blood

pressure may also be demonstrated. CT Scanning, and possibly M.R.I., is

indicated in those patients presenting with exertional aspects to their

headaches. Other neurological signs, such as headache accompanied by

fainting, should alert the emergency physician to the need for further

testing and referral to the appropriate specialist.

Disease of adjacent nasal and aural structures will usually be the cause of

the headache due to brain abscess. This pain will typically start at those

sites prior to the involvement of the cerebral parenchyma. The development

of papilledema and other signs of localized traction and generalize

displacement of the brain will usually herald a brain abscess. These

patients will also present with associated symptoms such as fever,

leukocytosis, and pleocytosis. Ear infections will most often produce

abscesses above or below the tantrum. Hiccoughing, vomiting, and occipital

headache are typical of abscesses below the tentorium. Pain in the frontal

region adjacent to the diseased frontal, ethmoid, and sphenoid sinus usually

result from an epidural abscess due to a sinus infection.

The patient should be questioned about recent or concomitant ear infections

or sinusitis. The presence of fever and purulent nasal drainage are

indicative of the need for CT Scanning and possibly sinus x-rays. The

possibility of a brain abscess should be suspected in a patient presenting

with recent onset headache, and no other clinical signs except for an

elevated white blood cell count. Referral to the appropriate specialist is

indicated, and immediate antibiotic therapy should be instituted.

HYPERTENSIVE HEADACHE

A frequently occurring presentation at the ED is the patient with

hypertensive headache. Characteristically, the headache is worse upon

awakening, and gradually improves throughout the day. The diagnosis can only

be confirmed with a diastolic blood pressure of 100 Hg or over. The degree

of elevation in blood pressure may or may not affect the severity of the

headache. Typically, the hypertensive headache is bilateral and usually

occurs at the occiput. It can also involve the entire head. Patients will

describe the pain as throbbing or " bursting " in nature and very severe.

Tremors or palpitations or other symptoms of catecholamine release, may

occur.

Essential hypertension does not usually cause headache. However, headache

due to increased blood pressure may be a manifestation of another disorder.

A sudden increase in blood pressure due to acute nephritis or acute pressor

reactions may produce a similar headache.

MIGRAINE

Between 4.5 and 20 percent of patients presenting to the ED with headache

will be suffering from migraine.3 Distinguishing migraine from an acute

life-threatening medical emergency is simplified by an accurate history and

physical examination. The patient with migraine will consistently report a

prior history of this type of headache. Usually, patients will consult the

emergency physician due to the severity of the headache as well as the

associated gastrointestinal and neurological symptoms.

The neurological examination is typically negative. However, the blood

pressure may be elevated during an acute attack. The patient presenting with

status migraine may appear dehydrated due to prolonged vomiting. Laboratory

evaluation of serum electrolytes is indicated. Hospitalization may be

indicated in order to stabilize the patient, initiate IV fluid replacement,

and provide analgesia.

COMPLICATED MIGRAINE

The patient with complicated migraine may present at the ED because of the

severity of the associated neurological symptoms. These symptoms are

typified by hemiphegic migraine, manifested by hemipareses and

opthalmoplegic migraine, with defects of the third and occasionally the

fifth cranial nerve. Neurologic symptoms often persist after the resolution

of the headache attack. A previous history of headaches may be a clue in

identifying the complicated migraine. CT Scanning may be indicated, and a

lumbar puncture may be considered if these symptoms persist.

BASILAR ARTERY MIGRAINE

Many patients with a specific form of complicated migraine, basilar artery

migraine, are often misdiagnosed in the ED because basilar artery migraine

is manifested by several neurological deficits. The headache is

characteristically severe and paroxysmal, and occurs predominantly in

females during adolescence and the third decade.

The diagnosis can be established by the presence of any three of the

following symptoms:

1) bioccipital headache;

2) impairment or loss in the temporal and nasal fields of both eyes;

3) Disturbed oculomotor function, such as diplopia or nystagmus;

4) Dysarthria;

5) Vertigo;

6) Tinnitus or impaired hearing

7) Ataxia of gait;

8) Bilateral paresis;

9) Bilateral paresthesia; or

10) Altered consciousness, such as amnesia, confusion, somnolence, stupor or

syncope.

Due to the variety of symptoms, basilar artery migraine may be confused with

a mental disorder, brain tumor or drug abuse. Differential diagnosis

includes tumors of the posterior fossa, thrombosis of the basal artery or

cerebral veins, cerebellar hemorrhage or infarction, drug intoxication, or

metabolic disorders. It is essential that the emergency physician obtain a

history of similar headaches in the patient or in the patient's family. Once

the diagnosis is established, treatment with standard migraine prophylactic

agents is recommended; and the patient should be referred for follow-up

care.

CLUSTER HEADACHES

Cluster headache is a form of vascular headache that is not as common as

migraine. This type of headache is usually easy to differentiate from other

headache conditions because of its characteristic presentation of severe,

unilateral headache, typically localized around one eye. A male predominance

prevails in cluster headaches, and the initial onset usually occurs between

the third and fifth decades.

Cluster headache is personified by its episodic pattern, occurring in series

usually lasting from three weeks to three months. During the series, the

acute headache will occur several times per day, and often awakens the

patient in the first few hours after falling asleep. Characteristically, the

acute cluster headache has a very limited duration. The headache may been

abated before the patient could arrive at the ED. However, the pain of

cluster is extremely excruciating, and this headache sufferer may present in

severe distress. The emergency physician should be aware that many cluster

headache patients have contemplated suicide during a cluster series because

of the severity and regularity of the pain.

The emergency physician may note an increase in the number of cluster

headache patients visiting the ED during spring and fall. A previous history

of cluster headaches will aid in the diagnosis. The associated symptoms of

nasal congestion, rhinorrhea, ptossis, and conjunctival injection may

confuse the picture, and acute sinusitis must be ruled out.

TENSION-TYPE (MUSCLE CONTRACTION HEADACHE)

The patient with tension-type, muscle contraction, headaches will usually

obtain relief with over-the-counter analgesics and simple relaxation

methods. Most patients with this type of headache experience the pain on an

episodic basis. However, some patients will report a daily, chronic

headache. Because of the chronicity of these headaches, habituating

analgesics must be avoided, particularly in the ED. Many patients with

chronic tension-type headaches have an underlying depression, as evidenced

by the presence of a sleep disturbance.[12] Narcotic analgesics, sedatives,

and tranquilizers should be strictly avoided in all settings. Those patients

with chronic tension-type headaches require an appropriate referral to a

physician or clinic familiar with the treatment of such.