Management of Severe or Dangerous Headaches

7/27/2019 Management of Severe or Dangerous Headaches

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MANAGEMENT OF SEVERE OR DANGEROUS HEADACHES

Ana Recober , MDRoy J and Lucille A Carver College of Medicine

University of IowaIowa City, IA

INTRODUCTION

Headache is the fifth most common complaint in the ED, representing about 2% of all ED visits in the US[McCaig, Adv Data 2006].

While the majority of the patients are found to have primary headaches (60% of them migraine), 25 % are foundto have a secondary headache and 10% of the patients have a coexisting primary and secondary headache[Friedman, Ann Emerg Med 2007]

The role of the physician in the ED is to rule out and treat potentially life-threatening conditions presenting asheadaches and to provide headache relief. In the case of primary headaches, an accurate diagnosis of theheadache disorder (migraine, tension-type headache, cluster headache, other trigeminal autonomic cephalalgias,

etc) is also important to provide appropriate acute treatment.

Here we will discuss the approach to diagnosis of acute non-traumatic headaches presenting to the emergencydepartment, focusing on the identification and appropriate evaluation of potentially dangerous headaches, as wellas the treatment of severe primary headaches.

EVALUATION OF ACUTE NON-TRAUMATIC HEADACHES IN THE ED

History: A careful history is crucial when evaluating a patient with headaches.

In the ED we need to obtain a detailed description of the current headache, including:

- Onset (What was the patient doing when the headache started? Did it start suddenly or slowly?)

- Duration of the headache

- Progression (constant, fluctuating, intermittent or progressively worsening from onset without improvement?)

- Severity (current, maximum severity and time to reach maximum severity)

- Quality of pain (sharp, pressure-like, throbbing, burning)

- Location of pain (presence of neck pain, irradiation of pain)

- Associated symptoms (autonomic symptoms, nausea, photo/phonophobia, neck pain)

- Modifying factors (triggers, aggravating and ameliorating factors)

In addition to obtaining a detailed description of the current headache, it is important to ask the patient aboutprevious headaches and carefully compare them. I find very helpful to ask patients if they feel that the currentheadache is different from previous ones and what makes it different.

Information about previously effective treatments for headaches and medications taken during the previous 24hours for the current headache should be documented, including over-the-counter medications.

A careful review of systems will guide our differential diagnosis.


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Finally, we must obtain a complete past medical history, including current medications, recent medicationchanges, drug allergies and/or adverse reactions, as well as relevant family and social history.

Physical examination: A thorough physical exam must include vital signs, cardiac exam, assessment of cranialstructures (teeth, eyes, ears, sinuses, pericranial muscles, temporal arteries), neck movements to rule out signsof meningeal irritation, head and neck auscultation to rule out bruits, mental status evaluation, fundi exam to ruleout papilledema, cranial nerves examination, and assessment of strength, reflexes, coordination, sensation andgait to rule out focal signs.

Red Flags Features of the history or exam that raise concerns of secondary headache:

New onset headache, new headache type or change in pattern of previous primary headache, especiallyafter age 50

Progressively worsening headache

New level of pain (worst headache of patients life)

Abrupt onset headache (Thunderclap headache)

Headache initiated by exertion or Valsalva maneuver

Neurological symptoms or signs (excluding typical aura)

Systemic symptoms or signs (fever, weight loss, scalp artery tenderness, nuchal rigidity)

Secondary risk factors (Hx of cancer or immunosuppression)

Differential diagnosis of thunderclap headache: Thunderclap headache is an acute headache with a suddenonset and maximum severity of pain at onset [Schwedt, Lancet Neurol 2006]. Primary thunderclap headache canbe recurrent and usually has a benign course, but remains a diagnosis of exclusion. The following conditionsshould be suspected and ruled out in any patient presenting with a thunderclap headache [Schwedt, LancetNeurol 2006]:

Subarachnoid hemorrhage

Sentinel headache

Cerebral venous sinus thrombosis

Cervical artery dissection

Spontaneous intracranial hypotension

Pituitary apoplexy

Retroclival hematoma

Acute ischemic or hemorrhagic stroke

Acute hypertensive crisis

Reversible cerebral vasoconstriction syndrome

Third ventricle colloid cyst

Intracranial infection


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Primary cough, sexual, and exertional headache

Primary thunderclap headache

Testing: Routine blood tests are usually normal and may not assist much with the diagnosis except for anelevated erythrocyte sedimentation rate, which suggests giant cell arteritis or infection.

A non-contrast head CT scan is usually obtained first when a secondary headache is suspected. A normal non-

contrast head CT does not preclude a secondary headache. Furthermore, the sensitivity of CT to detectsubarachnoid blood decreases with time (92% first 24 hours, 86% one day later, 76% two days letter, and 50% atone week) [Edlow, New Engl J Med 2000]. Even when interpreted by neuroradiologists, modern CT imaging is97.5% sensitive [Morgenstern, Ann Emerg Med 1998]

Lumbar puncture should always be performed when subarachnoid hemorrhage is suspected if non-contrast headCT scan is negative, equivocal, or technically inadequate [Edlow, New Engl J Med 2000]. CSF xanthochromia is93% sensitive, 95% specific, and has a 72% positive predictive value, and 99% negative predictive value [Dupont,Mayo Clin Proc 2008].

Further diagnostic tests such as brain MRI with and without gadolinium, head and neck MRA, MRV, and cerebralangiography may be required based on the suspected diagnosis.

The following table summarizes the most common tests used for evaluation of headache in the ED and theirspecific indications:

Suspected diagnosis Test

Mass lesion, SAH, stroke

Mass lesion, vascular anomaly (arterialdissection, AVM, aneurysm, venousthrombosis, stroke, Chiari malformation, CSFleak)

Aneurysm, AVM, vasculitis, venous thrombosis,

arterial dissection

Meningitis, SAH, IIH, CSF leak

Acute sinusitis

Giant cell arteritis

Infection

Hypoxemia/hypercarbia

Thyroid disease

Lyme disease

Drugs/alcohol

CT scan

MRI, MRA, MRV

Angiography

Lumbar puncture

Maxillofacial CT

ESR and CRP

WBC and blood cultures

Arterial blood gases

TSH/T4

Lyme antibodies

Drug/alcohol screen

TREATMENT OF SEVERE HEADACHES IN THE ED

The management of secondary headaches is usually directed to treating the underlying cause of the headache.In the case of primary headaches, the goals are to: 1) provide effective, fast and sustained relieve of pain andassociated symptoms, 2) restore the patients ability to function, 3) minimize the need for rescue medications, and


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4) avoid adverse events. Finally, appropriate referral for definitive headache management should be arrangedupon discharge from the ED.

There are some general principles that apply to the acute treatment of primary headaches regardless of the typeof headache:

Provide a quite, cool, darkened room for the patient to rest

Reassure the patient

Administer IV hydration when necessary

Treat nausea and vomiting aggressively and quickly

Use headache-specific medications whenever possible depending on the primary headache disorderdiagnosed (migraine, cluster, tension-type headaches)

Use effective doses and appropriate routes of administration (usually parenteral in ED setting)

Limit opioids to refractory situations or when other drugs are contraindicated

Educate the patient about their condition and about future outpatient acute treatment

Acute Treatment of Migraine in the ED

There are several guidelines available addressing the acute treatment of migraine:

US Headache Consortium for the AAN [Silberstein, Neurology 2000]

American Academy of Family Physicians and the American College of Physicians-American Society ofInternal Medicine [Snow 2002]

Canadian Association of Emergency Physicians [Ducharme 1999]

Canadian Medical Association [Pryse-Philips 1997]


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The following table summarizes the medications recommended for acute treatment of migraine by the USHeadache Consortium that are more relevant to the ED setting [Silberstein, Neurology 2000]:

Group 1:

Proven, pronounced statistical and clinicalbenefit (at least 2 double-blind, placebo-controlled studies and clinical impression ofeffect)

Sumatriptan SC/IN

DHE (IV/IM/SC/IN) w/wo antiemetic

Prochlorperazine IV

Butorphanol IN

Group 2:

Moderate statistical and clinical benefit (1double-blind, placebo-controlled studiesand clinical impression of effect)

Prochlorperazine IM/PR

Chlorpromazine IV/IM

Metoclopramide IV

Ketorolac IM

Lidocaine IN

Meperidine IM/IV

Buthorphanol IM

Methadone IM

Group 3:

Statistically but not proven clinically orclinically but not proven statistically(conflicting or inconsistent evidence)

Metoclopramide IM/PR

Group 4:

Proven to be statistically or clinicallyineffective (failed efficacy versus placebo)

Chlorpromazine IM

Granisetron IV

Lidocaine IV

Group 5:

Clinical and statistical benefits unknown

(insufficient evidence available)

Dexamethasone IV

Hydrocortisone IV

Despite strong evidence supporting the use of triptans, DHE and dopamine antagonists (prochlorperazine,chlorpromazine, and metoclopramide) for acute treatment of severe primary headaches in the ED, a study thatincluded 100 million ED visits in the US (1998 National Hospital Ambulatory Medical Care Survey) revealed thatthe most commonly used medications were meperidine (30%), ketorolac (21%), and prochlorperazine (17%).Promethazine and hydroxyzine, which dont have anti-headache effects, were used 6 times more commonly asadjunct antiemetics of parenteral opioids than the dopamine antagonists (prochlorperazine, chlorpromazine, andmetoclopramide) [Vinson, Ann Emerg Med 2002].

Triptans

Sumatriptan 6 mg SC is the triptan of choice in the ED. Importantly, sumatriptan 6 mg SC has been

demonstrated to be effective for the acute treatment of undifferentiated primary headaches (migraine, probablemigraine and tension-type headaches) in the ED [Miner, Am J Emerg Med 2007]. Common adverse effects oftriptans include chest and neck tightness, paresthesias, flushing, and dizziness. Triptans are contraindicated inpatients with cardiovascular disease, uncontrolled hypertension, severe peripheral vascular disease, basilar orhemiplegic migraine, patients that have used ergots or other 5-HT1 agonists within the previous 24 hours or MAOinhibitors during the previous 2 weeks. Triptans are contraindicated in pregnancy, although registry data does notshow an increase in rates of birth defects. Sumatriptan is considered compatible with lactation.


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IV DHE

Intravenous DHE administered every 8 hours [Raskin, Headache 1990] or as a continuous infusion [Ford,Headache 1997] are effective ways to treat transformed migraine.

To avoid nausea, premedication with metoclopramide 10 mg IV, prochlorperazine 10 mg IV, or chlorpromazine12.5 mg IV, should be used 15 min prior to DHE 0.5 mg IV. Benztropine mesylate 1 mg IV or diphenhydramine25 mg IV may be considered prior to the antiemetic to avoid extrapyramidal symptoms. If the first dose of DHE is

well tolerated, without unstable blood pressure or chest pain, then a second dose of DHE 0.5-1 mg IV can begiven 1 hour later [Colman, Ann Emerg Med 2005].

The Raskin protocol (DHE 0.5 mg IV q8h) [Raskin, Headache 1999] and the Ford protocol (DHE 3 mg IV in 1 lit ofnormal saline continuous infusion over 24 hours) [Ford, Headache 1997] may be more convenient in the inpatientsetting, but they are worth consider in some cases in the ED.

Limitations to treatment with DHE include previous use of triptans within 24 hours, hypertension, intractablenausea, and pregnancy.

Antiemetics

Prochlorperazine is probably one of the best studied antiemetics for the treatment of migraine. A recent meta-

analysis concluded that phenothiazines used for acute treatment of migraine (prochlorperazine andchlorpromazine) are superior to placebo and also clinically preferable to other agents (metoclopramide,meperidine, ketorolac, valproate, and sumatriptan) [Kelly, Headache 2009].

A randomized, double-blind, placebo controlled trial comparing a combination of prochlorperazine 10 mg IV +diphenhydramine 12.5 mg IV with sumatriptan 6 mg SC showed that prochlorperazine with diphenhydramine ismore effective than subcutaneous sumatriptan in the ED setting, without differences in sedation, nausea andheadache recurrence [Kostic, Ann Emerg Med 2010]

A single dose of prochlorperazine 10 mg IV was more effective than Ketorolac 30 mg IV in the ED setting [Seim,Acad Emerg Med 1998].

In another randomized, double-blind clinical trial, also in the ED, prochlorperazine 10 mg IV was superior tovalproate 500 mg IV infusion in reducing pain, nausea and the need for rescue treatment [Tanen, Ann Emerg Med2003]. In this study, prochlorperazine reduced pain within 30 min and nausea within 15 min.

A randomized controlled trial comparing prochlorperazine 10 mg IV with metoclopramide 20 mg IV (both incombination with diphenhydramine 25 mg IV) demonstrated that both drugs are equally effective and tolerated[Friedman, Ann Emerg Med 2008b)

Metoclopramide has also been compared with sumatriptan SC for acute treatment of migraine in the ED. In arandomized, double-blind, clinical trial, patients received sumatriptan 6 mg SC once or metoclopramide 20 mg IVevery 30 min for 2 hours. The group that received metoclopramide was also given diphenhydramine 25 mg withmetoclopramide at 0 and 60 min, which may have some added beneficial effect on the headache.Metoclopramide and sumatriptan were comparable in pain control at 2 and 24 hours and headache recurrencealthough there was a trend favoring metoclopramide [Friedman, Neurology 2005]. Metoclopramide 20 mg IVevery 30 min for 2 hours may represent a good alternative to sumatriptan in patients that have already used

triptans prior to their visit to the ED or when triptans are contraindicated for any other reason. A recentrandomized, double-blind, dose finding study did not reveal any superiority of metoclopramide 20 or 40 mgcompared with 10 mg IV [Friedman, Ann Emerg Med 2011].

Chlorpromazine 0.1 mg/Kg IV was superior to placebo in a double-blind randomized trial, resulting in bettercontrol of pain and associated symptoms at 30 min and 2 h, and lower recurrence rates and need for rescuetreatment. Sedation and hypotension occurred more commonly with chlorpromazine [Bigal, J Emerg Med 2002].Another randomized, double-blinded study found that 0.1 mg/kg/dose IV of either chlorpromazine ormetoclopramide were comparable and effective [Cameron, Acad Emerg Med 1995]. A small prospective,randomized, double-blind trial found no difference between ketorolac 60 mg IM and chlorpromazine 25 mg IV[Shrestha, Arch Intern Med 1996]


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Meperidine

In a recent meta-analysis meperidine was compared with non-opioid treatments (dihydroergotamine, antiemeticalone, or ketorolac) [Friedman, Ann Emerg Med 2008]. Meperidine (50-100 mg) was found to be less effectivethan dihydroergotamine, trended toward less efficacy than antiemetics (chlorpromazine, metoclopramide,droperidol, prochlorperazine, and methotrimeprazine); and was similar to ketorolac. Meperidine caused moresedation and dizziness than dihydroergotamine, similar gastrointestinal side effects and sedation as ketorolac,and less akathisia than antiemetics [Friedman, Ann Emerg Med 2008].

Despite this, meperidine was found to be the most commonly administered opioid patients treated with opioids,the majority (77%) did not receive any non-opioid ab(70%) in a study across different EDs in the US and it wasalso noted that among ortive headache medication [Vinson, Ann Emerg Med 2002].

Opioids should be limited to very specific circumstances where other first line headache medications arecontraindicated

Acute Treatment of Mig raine in the Pediatric Populat ion

Sumatriptan 5 and 20 mg nasal spray have shown to have the most favorable profile (class I) based on thepractice parameter for pharmacological treatment of migraine headache in children and adolescents from theAmerican Academy of Neurology Quality standards Subcommittee and the Practice Committee of the Child

Neurology Society [Lewis, Neurology 2004]. There is insufficient data regarding oral or subcutaneoussumatriptan in this population.

Antiemetics remain an option for children and adolescent, but further research is needed [Walker, Curr OpinPediatr 2008], [Bailey, Ped Emerg Care 2008]. In a randomized, double-blind trial prochlorperazine IV (0.15mg/kg, max 10 mg) was found to be superior to ketorolac IV (0.5 mg/kg, max 30 mg) [Brousseau, Ann EmergMed 2004].

Acute Treatment of Mig raine dur ing Pregnancy

Most pregnant women report an improvement of their migraine during the second and third trimesters, but insome cases migraine may worsen during the first trimester. The lack of controlled and safety studies in pregnantwomen makes recommendations difficult. Because pregnancy is an exclusion criterion in most clinical trials,there is no evidence that the effective therapies discussed above for acute migraine treatment are effective orsafe for pregnant women. Nevertheless, in cases of severe refractory migraine, hydration in combination with aninjectable dopamine antagonist, and a triptan may be considered [Lucas, Curr Pain Headache Rep 2009].

Data from manufacturer-sponsored pregnancy registries, retrospective and observational studies suggest thatsumatriptan is safe during pregnancy and breastfeeding and does not increase the risk of birth defects [Duong,Can Fam Physician 2010] [Evans, Ann Pharmacother 2008].

Opioids are frequently used during pregnancy although they should be used with caution. Dihydroergotamine andvalproic acid are contraindicated in pregnancy.

Acute Treatment of Cluster Headache in the ED

A recent randomized trial has confirmed the efficacy of inhaled oxygen at 100%, 12 L/min, by face mask, for 15

minutes resulting in pain resolution in 15 min [Cohen, J AMA 2009]

Sumatriptan 6 mg SC is the most effective medication for the acute treatment of cluster attacks [The SumatriptanCluster Headache Study Group, N Engl J Med 1991]. Alternatives to subcutaneous sumatriptan are intranasalsumatriptan 20 mg [van Vliet, Neurology 2003] and intranasal zolmitriptan 5 and 10 mg [Cittadini, Arch Neurol2006], although these take longer to abort a cluster attack than sumatriptan SC.

Intravenous DHE was also found effective in the acute treatment of cluster headaches [Mather, Headache 1991]and may be a good alternative to sumatriptan for those that do not respond to or cannot tolerate sumatriptan[Baron, Headache 2010].


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Intranasal lidocaine 4% ipsilateral to the pain may be considered as co-adjuvant therapy but should not be usedalone to abort an attack [Robbins, Headache 1995]

Finally, peripheral nerve blocks and trigger point injections may have a role in the management of acute clusterattacks in the ED setting, but more research is needed to confirm this [Ashkenazi, Headache 2010], [Scattoni,Headache Pain 2006], [Ambrosini, Pain 2005].

SUMMARY

Headache represents one of the more common reasons adults seek care in the emergency department (ED).

The main goal when evaluating non-traumatic headaches in the ED is to distinguish between primary andsecondary headaches. Secondary headaches can be benign or dangerous and occasional life-threatening.

The majority of the headaches seen in the ED represent primary headaches, but an accurate diagnosis to rule outsecondary headaches is crucial. One must carefully evaluate the patient with a detailed history and thoroughphysical examination to determine if further investigation is required.

The following red flags warrant further specific diagnostic investigation:

New onset headache, new headache type or change in pattern of previous primary headache, especially

after age 50

Progressively worsening headache

New level of pain (worst headache of patients life)

Abrupt onset headache (Thunderclap headache)

Headache initiated by exertion or Valsalva maneuver

Neurological symptoms or signs (excluding typical aura)

Systemic symptoms or signs (fever, weight loss, scalp artery tenderness, nuchal rigidity)

Secondary risk factors (Hx of cancer or immunosuppression)

After evaluating the patient, we must decide if inpatient care is required for further investigation and/or treatment.If outpatient care is considered appropriate and safe, then headache treatment in the ED should provide effective,fast and sustained relieve of pain and associated symptoms preserving functionality as much as possible.Appropriate referral for definitive headache management should be arranged before discharge from the ED.

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Management of Severe or Dangerous Headaches

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