1. Headache Treatment: What’s the Latest?

2. Philip Bossart, MD
Professor Division of Emergency Medicine University of Utah College of Medicine Salt Lake City, Utah 54 1 54

3. Session Objectives How to Diagnose Life Threatening Causes of Headache
How to Diagnose Migraine Headaches
How to Treat Migraine Headaches in the ED

4. Cartoon
What fits your busy schedule better, exercising one hour a day or being dead 24 hours a day?

5. Clinical Case
20 year old female has a chief complaint of headache. HA started 6 hours ago. Similar but milder HAs in the past. Prior headaches resolved with ibuprofen and rest but not today’s. Pain is bilateral, 10/10 intensity, with photophobia and phonophobia. She noted blurry vision before headache. Denies nausea, fever, focal weakness or numbness. She is late for her period.

6. Case Presentation (cont’d)
Her exam shows a BP of 120/80, HR of 70, RR of 20 and she is afebrile. She is alert and Ox3 but is in significant distress from pain. Scalp is tender, pupils 2 mm and reactive. Heart, Lung, and Abdominal exam are normal. GCS is 15. Cranial nerves and motor, sensory cerebellar and DTR testing is all normal.

7. Case Presentation (cont’d)
What tests need to be performed if any?
What is the most likely diagnosis?
How should she be treated?

8. Key Clinical Questions
What are the life threatening causes of acute headache?
What are the “red flags” which suggest a serious secondary HA?
What are the IHS criterea for migraine?

9. Key Clinical Questions (cont’d)
How should migraines be treated in the ER?
What are the contraindications to Triptans and DHE?

10. Life Threatening Causes of Headache
Intracranial bleed (esp. SAH)
Meningitis
Carotid or vertebral dissection
Sinsus thrombosis

11. Other Serious Secondary HAs
Mass lesions, intracranial hypertension, temporal arteritis, hypertensive encephalopathy, hypoxia, hypercapnea, CO toxicity, glaucoma

12. What are the “red flags” which suggest a serious headache?
Thunderclap headache: SAH, vascular dissection, venous thrombosis, pituitary apoplexy.
Headache onset during exertion: SAH or dissection
HIV and Immunosuppression: infections and tumors

13. “Red Flags” (cont’d)
New onset headache over age 50: mass lesions and temporal arteritis
Any neurologic sign or symptom: This is the best predictor of intracranial pathology. Look for papilledema, Horner’s syndrome, glaucoma. (Exception is typical migraine aura.)

14. “RED FLAG” Mnemonic “S N O O P S”
SYSTEMIC SYMPTOMS (e.g. fever,weight loss)
NEUROLOGIC SYMPTOMS/SIGNS
ONSET (SUDDEN)
OLD AGE (50 YEARS)
PRIOR HISTORY (New Headache)
SECONDARY ILLNESSES (AIDS, CANCER)
This is a mnemonic you may see

15. What are the IHS criterea for diagnosing migraines?
At least 5 episodes
4 to 72 hour duration
At least 2: unilateral location; pulsating; moderate to severe; aggravated by activity
At least 1: nausea and/or vomiting; photophobia and phonophobia
History and Exam do not suggest another diagnosis

16. How should migraines be treated in the ER?
Migraine specific medications (triptans, DHE, phenothiazines) are preferred
Parental route if severe, long standing, or vomiting.
Many medication choices without good data on best one to use

17. Migraine Treatment (cont’d)
Phenothiazine
Triptan or DHE
Ketorolac
Valproic Acid
Narcotics

18. Migraine Treatment (cont’d)
Prochlorperazine 10mg IV or Metachlopramide 10mg IV, Followed by: DHE 1mg IV if nec.
Sumatriptan 6mg SQ followed by phenothiazine if nec.
Some add diphenhydramine 25mg IV to phenothiazine to prevent akasthesia

19. Migraine Treatment (cont’d)
Ketorolac 30mg IV or IM
Chlorpromazine .1mg/kg IV (diluted in 20 cc saline) watch for hypotention
Valproic acid 500mg to 1000mg IV
Intranasal Lidocaine
Narcotics

20. What are the contraindications to Triptans and DHE?
Widely used medications with excellent safety profile
Chest pain is common but not serious and is not necessarily ischemia

21. Contraindications to Triptans and DHE (cont’d)
Known CAD or CVD
Uncontrolled hypertension
Pregnancy
Hemiplegic or basilar migraine
Within 24 hours of prior use

22. Case Conclusion No red flags CT scan not indicated
The only lab test done was a pregnancy test which was positive
Diagnosed with “migraine with aura”

23. Case Conclusion (cont’d)
Pregnancy reduces migraines in most patients but may get worse
Triptan and DHE contraindicated since she is pregnant
Treated with Prochlorperazine 10mg IV with prompt relief of HA

24. Case Conclusion (cont’d)
Since she was pregnant and had infrequent attacks, no preventive medications were given
Discharged home with OB folllow up.

25. Questions??
Philip Bossart, MD
ferne_2005_aaem_france_bossart_ha_fshow.ppt 8/27/2005 2:38 AM 54 54 1