Evaluation and Treatment of Headache Patients in the Emergency Department: A Survey.

SYNOPSIS
Patients with headache represent a common diagnostic and treatment challenge for health care providers in the emergency department. The therapeutic options continue to grow, yet many studies imply that narcotics continue to be a frequently chosen treatment. In this retrospective cross-sectional survey, the evaluation and treatment patterns of patients presenting to an academic medical center emergency department with a primary diagnosis of headache were analyzed. Headache disorders accounted for 1.7% of all visits to the emergency department. Migraine headache was the most common headache diagnosis representing 60% of headache visits followed by headache of no obvious source at 25%. Narcotics were the most common treatment employed (180 patient-visits) in all patients and non-steroidal anti-inflammatory agents were the second most common agent used (86 patient visits). Narcotics were also the most common therapy in migraine headache patients (152 patient-visits) while ergotamines were used in less than one-third of patient-visits (36 patient-visits). Therapy of headache patients in the emergency department continues to rely on narcotics. Methods of interrupting the dependence on narcotics need to be explored if newer non-narcotic therapies are to be successful.     

Chronic daily headache: When to suspect meningitis

Millions of patients see physicians each year for headache, most of which are primary headaches. However, serious secondary headaches, such as meningitis, represent about 5% of children and 1% to 2% of adults seen in the emergency department for headache. A primary care or emergency department physician may initially miss individuals with bacterial meningitis. Considering meningitis as a headache cause is important because delay in the diagnosis may have adverse consequences. A careful history and physical examination are central in identifying individuals at high risk for meningitis. This article lists information that can be obtained from the patient that may be indicative of meningitis. Performing a lumbar puncture with appropriate examination of the cerebrospinal fluid (CSF) is the key to establishing the diagnosis of meningitis. This article also includes the types of meningitis that should be considered when the CSF demonstrates a pleocytosis.     

Do ED patients with migraine headaches meet internationally accepted criteria?

A recent editorial criticized emergency medicine researchers who study the treatment of acute migraine for failing to standardize patients according to definitions provided by the International Headache Society (IHS). In fact, most emergency medicine-based studies of migraine therapies have not used IHS Criteria (IHSC) for patient inclusion and are not uniform in the definition of acute migraine. The purpose of this study was to determine the percentage of patients with complaint of headache who present to the emergency department with a prior diagnosis of migraine and/or emergency department discharge diagnosis of acute migraine that meet IHSC. The study was a prospective observational study performed in a community-based and consisted of consecutive patients with a chief complaint of headache who presented to any 1 of 6 study investigators. Patients recorded historical data on a standard form; Clinical data were recorded by the investigators. Ninety-five percent confidence intervals and the Fisher exact test were calculated as appropriate. One hundred eighty-five patients were enrolled (study group): 70% were women, 43% had prior imaging studies to diagnose the etiology of the headache, and 26% had a diagnostic workup during the current emergency department visit; the probable headache etiology was found in 12 of these cases. Only 3 patients that had an ED workup that fit IHSC. Forty-nine percent of all patients had a prior diagnosis of migraines; 41 of these patients (45%) met IHSC. Forty-two percent of all patients had an emergency discharge diagnosis of acute migraine; of these, 43 (56%) met IHSC. Forty-four out of 96 (46%; 95% confidence interval = 35%-57%) patients with a prior diagnosis of migraine and/or discharge diagnosis of acute migraine met IHSC. Modification of the IHSC, by removing restrictions for headache duration and number of prior episodes, would have markedly increased the percentage of patients with a previous migraine and/or emergency discharge diagnosis of acute migraine that met other qualitative IHSC (94%). Of the patients with prior migraine diagnosis and/or emergency department diagnosis of acute migraine, men and women were equally as likely to meet IHSC (41% v 48%, P = 0.79). Less than half of patients with a prior diagnosis and/or final emergency discharge diagnosis of acute migraine met IHSC. Our findings raise concerns about the external validity of prior emergency department-based research of acute migraine therapy and the utility of the IHSC for future research. Modification of the IHSC for emergency medicine research should be considered.     

Response of headaches to nonnarcotic analgesics resulting in missed intracranial hemorrhage

The differential diagnosis of headache is broad, ranging from immediately life-threatening to benign etiologies. Currently, headaches can be treated successfully with various nonnarcotic analgesics. Three cases are presented in which patients with headaches were treated in an emergency department with nonnarcotic analgesics which relieved their headaches; subsequently, these patients returned to be diagnosed with intracranial hemorrhage. Some nonnarcotic analgesics may relieve symptoms of intracranial hemorrhage through their recognized mechanisms of action. Avoiding such occurrences requires that the diagnosis of headache be made with careful consideration of the patient's history. A patient presenting with a new onset of severe headache or a headache that is different from those experienced in the past deserves a thorough diagnostic work-up including a computed tomography scan followed by lumbar puncture if indicated. Diagnostic decisions regarding headache should not be based on a patient's response to any analgesic, nonnarcotic or narcotic.     

The epidemiology of migraine: a retrospective study in Italian emergency departments

This study was conducted to measure the frequency of contact with emergency departments in Italy because of migraine, and to compare the initial diagnosi s of headache with the diagnosis after application of the International Headache Society (IHS) criteria. A retrospective observational method was used, consisting of an analysis of the records of patients admitted to nine Italian emergency departments during different 4-month periods in 1994. Comparison of the initial diagnosis with the diagnosis after application of the IHS diagnostic criteria was performed. More than 31 million emergency department contacts were reported in Italy during 1994. In the same year, 543 630 patients visited the nine emergency departments enrolled in the study, with 169 569 of these contacts occurring in the 4-month period analyzed in the study. We excluded from the analysis all cases of secondary headache fully recognized at the emergency department admission (ie, traumas, intracranial pathology, systemic diseases). The total number of patients included in our analysis was 1043 (0.6%). The 934 patients who could be fully evaluated were initially classified as having migraine; cluster headache; headache not otherwise specified; or diagnosed in the emergency department as suffering from headache, but reclassified by other departments as suffering from a different disease. After retrospective application of the IHS classification, the diagnostic distribution was modified, revealing that 18% of patients with migraine and 5% with cluster headaches had previously been classified as having headache not otherwise specified; a further 6% of cases with migraine and 0.4% of patients with cluster headache had previously been classified as having secondary headaches. The diagnosis of headache not otherwise specified was made with notable frequency, indicating the limits of emergency department logs and the difficulty in carrying out a retrospective analysis and reassessment of diagnosis. The majority (88%) of patients assessed had not taken drugs for headache in the 48 hours before the emergency department contact, suggesting that in Italy emergency departments are used instead of a visit to the general practitioner. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed drugs in the emergency departments for this group of diagnoses. The research revealed, on the one hand, that headache is a numerically significant phenomenon in the emergency department setting and, on the other, the need to apply prospective designs to this kind of survey.     

Evaluation and Emergency Treatment of Headache

Headache is a common complaint in patients presenting to the emergency department. Most such headaches are benign, but some have a more severe organic cause. Occasionally, patients present with a chronic headache disorder with which they can no longer cope. The new International Headache Society Classification of Headache is reviewed along with the differential diagnosis of benign headache disorders. Headache diagnosis by history is examined in detail followed by a discussion of the emergency presentation of headache patients. Causes for concern are presented, along with a detailed discussion of differential diagnosis, including subarachnoid hemorrhage, meningitis, sinusitis, glaucoma, internal carotid artery dissection, and cerebro-vascular disease. Also discussed are medications used for the symptomatic treatment of headache, including analgesics, NSAIDs, narcotics, and ergotamine preparations. Approaches to the treatment of the severe, persistent headache in the emergency department are outlined and treatment options suggested. Headache medication overuse is discussed and guidelines are presented to recognize the condition and prevent its recurrence.     

Late postpartum eclampsia coincident with postdural puncture headache: a case report

Preeclampsia developed in this patient 4 days' postpartum. Visual changes, headache, and elevated blood pressures were present on arrival to the emergency department. Coincident with the preeclampsia was a postdural puncture headache complicating the diagnosis of late postpartum preeclampsia. Pregnancy-induced hypertension laboratory values were normal, and relief of the postdural headache and visual disturbances was obtained after placement of an epidural blood patch. Blood pressures continued to increase, however, and late postpartum eclampsia developed. We conclude that symptoms of a postdural puncture headache can mimic those of postpartum preeclampsia. Early recognition and treatment of postpartum preeclampsia may decrease patient mortality and morbidity by preventing late postpartum eclampsia.     

Response of non-migrainous headaches to chlorpromazine

Chlorpromazine, given intravenously, is a useful agent in the treatment of acute migraine headaches. Patients with more serious conditions, however, may also respond to this medication. In this paper we report two patients who were initially diagnosed as having migraine headaches and treated with chlorpromazine. Both experienced temporary pain relief and it was only after repeated presentations to the emergency department that their conditions--a subarachnoid hemorrhage and a subdural hematoma--were accurately diagnosed. Because of this, caution must be exercised before re-treating within a short period of time, a patient with recurrent headache. Strong consideration must be given to an alternate diagnosis and such a diagnosis should be actively sought should there be any suspicion of a non-migrainous cause for headache. It is only by doing so that we may avoid missing more serious and life-threatening conditions such as those with which our patients presented.     

Distinguishing dural sinus thrombosis from benign intracranial hypertension

Dural sinus thrombosis (DST) is a life threatening illness and is often overlooked but it must be considered in the differential diagnosis of a patient presenting with a significant headache. DST presents similarly to benign intracranial hypertension (BIH) with intracranial hypertension and headache. A case of a 23 year old woman with DST is described that was initially diagnosed as BIH. A Medline search to determine the examination of a patient with suspected BIH or DST yielded several articles on this topic but only two brief case reports in the emergency medicine literature. Any patient with suspected DST or BIH must have a confirmatory magnetic resonance imaging and magnetic resonance venography study. Treatment of DST seems to be effective, considerably different from BIH, and lack of treatment may lead to increased morbidity and mortality.     

Thunderclap headache after micturition in bladder pheochromocytoma

A thunderclap headache is a sudden and severe headache and is sometimes a sign of a medical emergency such as aneurysmal subarachnoid hemorrhage and pituitary apoplexy. We report a case of pheochromocytoma in the urinary bladder in a 37-year-old man who presented with recurrent thunderclap headache after voiding and exercises. Bladder pheochromocytoma should be included in the differential diagnosis of recurrent thunderclap headache after micturition or exercises.     

Evaluation of the patient with nontraumatic headache: an evidence based approach

This article reviews the literature on the diagnostic tools available to make a cost-effective yet appropriate diagnosis in the patient with an atraumatic headache in the emergency setting. The tools addressed include a good history and physical examination alone, third-generation CT, lumbar puncture, and MR imaging. The epidemiology and characteristics of the more common primary and secondary causes of headache are also reviewed, allowing the clinician to develop a better pretest probability of disease, and make a more educated decision as to when additional diagnostic testing is needed.     

Emergency department treatment of migraine,tension, and mixed-type headache

The complaint of headache is frequently encountered in the emergency department, but most patients with cephalalgia have a benign etiology for their pain. At least 90% of patients presenting with headache are diagnosed as suffering from benign vascular or muscle-tension (for example, migraine, tension, or mixed-type) headache. There is no consensus on the ideal therapeutic approach to these patients. Classically utilized narcotic therapy suffers from problems with efficacy, relapse, and potential for abuse and addiction. However, other agents have successively proved to be imperfect as well, despite the many therapeutic approaches that have been suggested in the medical literature. While no one drug has emerged as clearly superior for treatment of acute benign headache, recent investigations have clarified the role of certain therapies. This review is intended to familiarize emergency physicians with the latest information on most recommended therapeutic approaches to the patient with headache.     

Epidural hematoma: an unusual presentation

The authors present a patient with a traumatic epidural hematoma who complained only of headache and presented to the emergency department 48 hours after a fall. Mental status and neurological examination were normal. This delayed presentation is more commonly seen when a subdural hematoma is present but may result from epidural bleeding. Delayed formation of a traumatic epidural hematoma may occur when the following are present: elevated intracranial pressure, hypovolemic shock, a concomitant mass lesion, coagulopathy, bleeding from dural or diploic veins, a dural sinus laceration, a traumatic pseudoaneurysm, or an arteriovenous fistula. Although criteria for computed tomography of patients with head injuries remain variable in the literature, delayed presentation of epidural bleeding must be considered in the differential diagnosis of posttraumatic headache irregardless of the time interval or neurological presentation.     

A simple treatment of post-lumbar-puncture headache

We report a case of post-lumbar-puncture headache successfully treated with intravenous caffeine sodium benzoate. The patient presented to the emergency department with a severe headache three days after a myelogram of the lumbar region. Caffeine sodium benzoate (500 mg) in 1 liter of fluid (D5LR) intravenously over one and a half hours was administered. The patient reported complete resolution of symptoms and no recurrence of headache. Caffeine sodium benzoate is a simple treatment of post-lumbar-puncture headaches. It should be considered as a safe alternative to an epidural blood patch for the treatment of post-lumbar-puncture headaches.     

Retropharyngeal phlegmon in a hemodialysis patient with Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia is a frequent occurrence in patients with indwelling catheters. Endocarditis, osteomyelitis, and septic arthritis are common metastatic complications. A hemodialysis patient developed fever, headache, neck pain, sore throat, and dysphagia in the setting of S. aureus bacteremia. Contrast computed tomography scan of the neck revealed a retropharyngeal phlegmon. Recurrent bacteremia led to the identification of the access graft as the infectious source. We present this case to increase awareness among emergency physicians that retropharyngeal infection by S. aureus can arise by hematogenous spread and should be considered in the differential diagnosis of a bacteremic patient with sore throat or neck pain.     

Cerebral venous thrombosis: Diagnosis and management in the emergency department setting

IntroductionCerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes.ObjectiveThis narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician.DiscussionCVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases.ConclusionsCVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.     

Emergency evaluation and treatment of headache

This article presents a practical approach to the problem of headache in the emergency setting, including a simplified method of diagnosis and a discussion of the major types of headache. Emphasis is placed on differentiating headaches caused by serious illnesses from the primary headache syndromes.     

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.