Diagnoses and Management of Acute Headache in the Emergency Department

1. Diagnoses and Managementof Acute Headachein theEmergency Department

2. Case I: 40 yo. F-brought to the ER by EMS, c/o severe HA. Describes HA as pounding in nature, diffuse, sudden onset, associated with N/V X 3 over the last several hours. Also c/o dizziness & blurry vision. PE: VSS-appears in moderate distress and remains recumbent on the examination table during the entire assessment. HEENT: PERRLA, EOMI but squints when testing pupillary response. Resists movement when asked to flex her neck and cries out when you attempt to assist her with neck flexion. Neuro exam: occasional slurring of speech and lethargy noted. Remaining of the Physical Exam is nl.

3. Case II: 42 yo. F-presents to the ER stating that she is having a migraine and is requesting narcotics for pain relief. She has a long hx. of migraines and usually receives an IM narcotic and is discharged home. She would have talked to her FP for this but she’s out of town. She was placed in urgent category by the triage RN because of stated degree of discomfort. She has received ergotamine and imitrex in the past w/out adequate response. She’s allergic to NSAIDs. PE: Sitting in a dark room with polarized sunglasses. She’s asking for pain relief and wondering aloud why you will not give it to her.

4. Headache Is a Major Public Health Problem. Up to 4% of ED Visits / 2% All Office Visits. Over 20 Million Outpatient Visits. 78 % of Women and 60% of Men Experienced at Least One Headache in the Year. 36% of Women and 19% Men Suffered From Recurrent Headaches

5. Potentially Life Threatening Etiologies Characterize Patients Presenting to the Emergency Department With a Chief Complaint of a Severe Headachein <5% of the Cases

6. Goals of Headache Management in the Emergency DepartmentPrimary Exclude Ominous Causes Provide Adequate Relief of PainSecondary Minimize Time Spent in the ED Establish Continuity of Care after discharge

7. History Establishing a diagnoses when a patient presents with a headache depends almost entirely on taking an accurate patient history and physical exam

8. Age of Onset Benign syndromes usually begin before middle age Ominous causes of headaches occur more frequently with advanced age (>40 years old)

9. Duration of complaint . Sudden onset: SAH or meningitis . Gradual or chronic: Migraine, tension HA Recently developed over several days,weeks or months -New onset migraine or tension-type headache -Increased Intracranial Pressure -Temporal Arteritis

10. Headache Location . helpful but nonspecific Unilateral: Migraine, cluster Bilateral/diffuse: Tension, Migraine Associated Symptoms . GI and Neurological symptoms most common example: eye pain, photophobia, N/V, syncope, fever, facial pain, jaw claudication, etc.

11. .Aggravating or relieving factors . Family History: Migraine & SAH .Other History MedicationsToxic exposures Trauma Hypertension HIV

12. PHYSICAL EXAM • Does the patient look ill? • Vital signs: fever, BP • HEENT & Neurological exams most important! • Fundoscopic exam Cranial nerves Mental Status Meningeal irritation Gait and reflexes Tenderness on palpation

13. In Summary…. To what extend should each patient be evaluated? Absolute clinical indications Worst headache everOnset associated with exertion Depressed cognition or neurologic deficit on exam Nuchal signs Deterioration during observation Conservative approach acceptable in patients Lack the above findings with normal VS Improvement during observation

14. Investigating Headache Is any special investigation warranted? When there is diagnostic difficulty or history suggests a serious disorder, investigation becomes obligatory! CT-Scan MRI Lumbar Puncture Blood Count/ESR

15. Headache Classification • User friendly IHS Classification • Primary Headaches • Benign Headache disorders • Migraine (with or without aura) • Tension-type headaches • Cluster headaches • Drug rebound headaches-Medication overuse headache Secondary Headaches Headaches that are symptoms of organic disease

16. Secondary HeadachesSubarachnoid Hemorrhage Meningitis Temporal Arteritis Hypertension Glaucoma Trauma Non-meningitic Infections Pseudotumor Cerebri Metabolic Disorders Toxic Substances Space Occupying Lesions Sinusitis

17. Subarachnoid Hemorrhage • sudden onset HA “unexpected clap of thunder” • most common location is “occipitonuchal” • excruciating pain,vomiting, obtundation • Diagnosis: CT-Scan, LP (xanthochromia) • Treatment: Seizure precautions • Nimodipine 60 mg. orally • Monitor BP • Neurosurgical evaluation

18. Meningitis • fever,stiff neck, mental status change • headache worse with eye movement • No papilledema or neurologic deficit seen • Diagnosis: LP • Treatment: start IV-Antibiotics immediately

19. Temporal Arteritis • usually over 50 yrs old • severe, throbbing temporal headache, jaw claudication, tender temporal artery • loss of vision due to optic neuritis • Dx: age >50, new onset HA, Temporal artery tenderness, elevated ESR (>50), (+) biopsy • Treatment: Steroids/Neurology consult

20. Primary Headache Etiology ????

21. Primary Headache Pathophysiology • Hypotheses (specific cause unknown) -Cortical spreading definition -Migraine generator -Vasodilation/inflammation -Peripheral sensitization -Genetic factors -Others….

22. International Headache Society Criteriafor MigraineMigraine Is an Episodic Recurrent HA lasting 4-72 Hours With: Any 2 of these pain qualities: . Unilateral pain . Throbbing pain . Pain worsened by movement . Moderate or severe pain Any 1 of these associated symptoms: .Neusea and/or vomiting .Photophobia and phonophobia

23. Primary Headaches • Migraine Headache • Currently 28 million migraine sufferers age 12+ in USA • -21 million females • -7 million males • Migraine prevalence peaks in the 25-55 age group • -25% of women aged 18-49 suffer from migraine • 1 in 4 households has at least 1 migraine sufferer

24. Migraine with Aura • due to primary neuronal dysfunction • corresponding decrease in blood flow to the area • visual auras most common • “flashing lights or dark spots” • lasts 30 minutes to one hour-fully reversible • ->60 minutes, r/o underlying ischemic/coagulopathic/embolic disorders • only seen in 15-20% of migraine patients

25. Cluster Headaches • Criteria for diagnoses: at least 5 attacks • Severe unilateral orbital, supra-orbital and/or temporal pain • lasting 15 to 180 minutes • At least one of the following on the headache side; • . Conjuctival injection . Lacrimation • . Facial/forehead sweating . Miosis • . Nasal congestion . Ptosis • . Eyelid edema . Rhinorrhea • Frequency: from one every other day to eight per day • More common in males • Treatment: Oxygen, Triptans, Ergots, Indocin, Steroids

26. Chronic Tension Headaches • Average frequency of attacks >15 days/month for 6 months • At least two of the pain characteristics; • 1. Pressing/tightening (non-pulsating) quality • 2. Bilateral location • 3. Not aggravated by routine physical activity • 4. Mild/moderate severity • Both of the following; • 1. No vomiting • 2. No more than one of the following: N, photophobia, phonophobia • No evidence of organic disease

27. Treatment of Benign Headache in the Emergency Department Parenteral Agents . Nonspecific analgesics: Narcotics . NSAIDs (Toradol) Neuroleptics/antiemetics . Phenothiazines (Thorazine, Compazine) . Metoclopramide (Reglan) Serotonin receptor agonists: Triptans, Dihydroergotamine

28. Narcotics Widely used, esp. IM forms Should be avoided for 3 reasons; . Less effective, deals with pain, treating only a symptom . Sedating, respiratory depression . Abuse potential Most useful in elderly and selected pregnant patients

29. Serotonin Receptor Agonists . Receptor specific agonists that stimulate serotonin (5-HT1) receptors to reduce neurogenic inflammation Dihydroergotamine (DHE) . Broader spectrum, affects serotoninergic, alpha-adrenergic and dopamine receptors Sumatriptan: Imitrex Others: Naratriptan(Amerge), almotriptan(Axert), rizatriptan(Maxalt), frovatriptan(Frova), eletriptan(Relpax), zolmitriptan(Zomig), etc.

30. D.H.E • Offers primary therapy, not just pain relief • Minimal side effects, mainly N/V • No physical dependence; non-narcotic • may be administered IV, IM, SQ and NS available • Venoconstrictor-has no arterial vasoconstrictor effects • General precautions; age over 60, DM and HTN • other side effects: leg cramps, chest tightness

31. DHE • IV/IM/SC: 0.25-1 mg., can be used 2-3x/day • Nasal Spray: 1 spray in each nostril (0.5 mg/spray) • may repeat in 15 mins (4 sprays=2 mg) • use no more than 2-3x/week, on separate days • Avoid use with macrolide antibiotics, in patients with • ischemic heart dz, uncontrolled HTN • Other ergotamine medications; • Ergotamine tartrate(ET): cafergot, Wigraine, etc. • available in oral, suppositories, sublingual(ergostat) • 2 tabs at onset, 1-2 q30-60 mins, max. 2-6/day • no more than 2 days/week • cannot be used within 24 hours of triptan medications

32. Administration of D.H.E Method I: Pretreat with 10 mg IV compazine over 2 mins Wait app. 20 mins, administer 0.5-1.0 mg DHE-slow IVP over 2 minutes Method II: Draw 1 mg DHE and 2 ml of compazine in a single 3-ml syringe Administer through single venopuncture via 2 min. slow IVP Method III: may use IM, slower onset of action

33. SUMATRIPTAN • Serotonin receptor agonist but differs from DHE • in 3 major respects; • Does not require use of an antiemetic agent, • has antiemetic properties of its own • Available in a SC auto-injectable format containing a • fixed 6-mg. dose and oral tablets • 3. Has a relatively short half life of about 2 hours • Patient acceptance very high with SC, oral and NS

34. SUMATRIPTAN • SC dose: 6 mg. May repeat in one hour • No more than 2 in 24 hours, limit 2 days/week • Oral: 25-100 mg tabs…take at onset, may repeat in 2 hrs • max. 100 mg/day • Nasal Spray: 5 or 20 mg. 1 spray in each nostril • may repeat in 2 hrs, max. 40 mg/24 hrs • Should not be used in patients with CV, cerebrovascular, • severe HTN, severe hepatic impairment, angina or PVD. • Do not take within 2 weeks of MAOI discontinuation

35. SUMATRIPTAN • Excellent migraine medication for select patients • Works rapidly, minimal nursing time and side effects • Recurrance of hadaches within 24 hrs-major objection • to its use-may need repeat dose • 2 deaths linked to this medication; • 1. Woman with COPD • 2. Patient w/CAD had MI 6 days after its use • No ECG changes documented with use • Pregnancy category C

36. DHE –vs-Sumatriptan • Both are highly effective in aborting headaches • DHE-IV requires treatment with anti-emetics, RN time • Imitrex may require repeat treatment within 2 hours • Side effects: similar • Cost: Sumatriptan injection app. $35/dose • Nasal Spray: $ 35.00 • DHE-45 1.0 mg injection app. $ 18.00/dose • Migranal NS: $ 43.00

37. Narcotic Seeking Patients • Demanding behavior • List of allergies • Unusual history and presentation • Difficult to deal with