Rosen & Barkin's 5-Minute Emergency Medicine Consult (319 page)

• Narcotics
  
• Corticosteroids
  

FOLLOW-UP

• Persistent headache unresponsive to usual measures
  
• Unclear headache diagnosis
  

• Patients with moderate to complete pain relief, a normal neurologic exam, and with a confident diagnosis of cluster headache
  
• Consider prescribing oxygen and/or SC sumatriptan for management at home
  

Follow-up with a neurologist should be arranged

• History is essential to diagnose cluster headache as pain may be improved upon presentation
  
• 100% oxygen should be the 1st treatment initiated
  
• Cluster headaches may be so severe that they lead to suicide
  
  • Follow-up is essential to manage clusters which may last months
    

• Cohen AS,Burns B, GoadsbyPJ. High-flow oxygen for treatment of cluster headache: A randomizedtrial.
  JAMA.
  2009;302:2451–2457.
  
• Friedman BW, Grosberg BM. Diagnosis and management of the primary headache disorders in the emergency department setting.
  Emerg Med Clin North Am
  . 2009;27:71–87.
  
• McGeeney BE. Cluster Headache Pharmacotherapy.
  Am J Ther
  . 2005;12:351–358.
  
• Nesbitt AD, Goadsby PJ. Cluster headache.
  BJM
  . 2012;344:e2407.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Headache
  
• Headache, migraine
  

CODES

• 339.00 Cluster headache syndrome, unspecified
  
• 339.01 Episodic cluster headache
  
• 339.02 Chronic cluster headache
  

BASICS

• Chronic episodic headache disorder
  
• Neurovascular pathophysiology:
  
  • Aberrant trigeminal nerve activation
    
  • Activation of nociceptive pathways within brainstem
    
  • Vascular dilation reactive rather than causative
    
  • No longer considered primarily a vascular headache
    
  • Disordered sensory processing and autonomic dysfunction
    
  • Cortical spreading depression underlies aura
    
• 1 million ED visits per year
  
• Causes majority of ED headache visits
  
• 3× as common in women
  
• Prevalence peaks in 4th decade of life
  
• Established criteria for migraine without aura:
  
  • A. 5 attacks fulfilling criteria B, C, D, E
    
  • B. Attack lasts 4–72 hr
    
  • C. Headache has 2 of the following:
    
    • 1. Unilateral location
      
    • 2. Pulsating
      
    • 3. Moderate to severe pain (impairs activities)
      
    • 4. Aggravation by or avoidance of physical activity
      
  • D. During headache, nausea, or vomiting and/or photophobia + phonophobia
    
  • E. Not attributable to other cause
    
• Migraine with aura:
  
  • Less common
    
  • Classically, reversible neurologic symptoms that precede headache
    
  • Some patients report aura at the same time or after the headache
    
  • Rarer subtypes of migraine include:
    
    • Basilar type migraine
      
      • Dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness
        
    • Hemiplegic migraine
      
      • Full reversible motor weakness
        
    • Retinal migraine
      
      • Repeated attacks of monocular visual disturbance
        

• More commonly bilateral pain and shorter duration of headache
  
• Associated symptoms may be difficult to elicit and can be inferred from behavior
  
• Cyclical vomiting syndrome associated with migraine
  
• High placebo response
  

Genetic disorder with variable penetrance, influenced by the environmental factors

DIAGNOSIS

• May be precipitated by chocolate, cheese, nuts, alcohol, sulfites, monosodium glutamate (MSG), stress, or menstruation
  
• Prodrome precedes migraine by several days
  
  • May consist of cognitive or emotional alterations, yawning, drowsiness
    
• Aura precedes migraine by 1 hr
  
  • Most commonly consists of visual or sensory disturbances
    
    • Scintillating scotoma
      
    • Fortification spectra
      
    • Numbness or tingling
      
• Headache typically unilateral, throbbing
  
• Sufficiently intense to impair activity
  
• Can be bilateral
  
• Usually associated with osmophobia, photophobia, phonophobia, nausea, or vomiting
  
• Usually gradual onset
  
• History often reflects similar headache previously
  

• Allodynia (sensitivity to normally non-noxious stimuli) may be present and signifies more refractory migraine
  
• Physical exam should otherwise be normal
  
• Physical exam should include exam of fundi and assessment of visual fields
  
• Elevated blood pressure does not exclude migraine as diagnosis
  
• Sinus tenderness does not exclude migraine as diagnosis
  

• An accurate history and physical exam confirm the diagnosis
  
• Patients with new headache syndrome may require workup including imaging and spinal fluid analysis
  

Clinical diagnosis: None required

Clinical diagnosis: None required

Clinical diagnosis: None required

• Cluster headache
  
• Medication overuse headache
  
• Tension-type headache
  
• Allergic or viral rhinosinusitis
  
• Idiopathic intracranial hypertension (pseudotumor cerebri)
  
• Reversible cerebral vasoconstriction syndrome
  

TREATMENT

• Allow patients with migraine headache to be in a calm, dark environment
  
• Oxygen may be beneficial
  

• Exclude secondary causes of headache
  
• Rapid and effective analgesia
  

• Detailed history will exclude secondary cause of headache in most patients
  
• Provide analgesia without relying upon opioid analgesics
  
• IV saline hydration is often helpful
  
• Provide patient with diagnosis – “You have a migraine”, education about trigger avoidance
  

Metoclopramide, prochlorperazine best treatment options in pregnancy

• Abortive therapy in ED:
  
  • Dopamine antagonists:
    
    • Prochlorperazine 10 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia
      
    • Droperidol 2.5 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia (check EKG prior)
      
    • Metoclopramide 10 mg IV
      
    • Trimethobenzamide 200 mg IM
      
  • Triptans:
    
    • Sumatriptan: 6 mg SC (avoid if cardiac risk factors)
      
    • Eletriptan 40 mg PO
      
  • Ergot alkaloids:
    
    • Dihydroergotamine: 1 mg IV, coadministered with an antiemetic (avoid if cardiac risk factors; avoid if on macrolide or antiretrovirals)
      
  • Nonsteroidals
    
    • Ketorolac 30 g IV
      
  • Corticosteroids
    
    • Dexamethasone 10 mg IV or IM
      
    • Prednisone taper