2 Philip Bossart, MDProfessor Division of Emergency Medicine University of Utah College of Medicine Salt Lake City, Utah54154
3 Session Objectives How to Diagnose Life Threatening Causes of Headache How to Diagnose Migraine HeadachesHow to Treat Migraine Headaches in the ED
4 CartoonWhat fits your busy schedule better, exercising one hour a day or being dead 24 hours a day?
5 Clinical Case20 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)MeningitisCarotid or vertebral dissectionSinsus 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 dissectionHIV and Immunosuppression: infections and tumors
13 “Red Flags” (cont’d)New onset headache over age 50: mass lesions and temporal arteritisAny 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/SIGNSONSET (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 episodes4 to 72 hour durationAt least 2: unilateral location; pulsating; moderate to severe; aggravated by activityAt least 1: nausea and/or vomiting; photophobia and phonophobiaHistory and Exam do not suggest another diagnosis
16 How should migraines be treated in the ER? Migraine specific medications (triptans, DHE, phenothiazines) are preferredParental route if severe, long standing, or vomiting.Many medication choices without good data on best one to use
17 Migraine Treatment (cont’d) PhenothiazineTriptan or DHEKetorolacValproic AcidNarcotics
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 IMChlorpromazine .1mg/kg IV (diluted in 20 cc saline) watch for hypotentionValproic acid 500mg to 1000mg IVIntranasal LidocaineNarcotics
20 What are the contraindications to Triptans and DHE? Widely used medications with excellent safety profileChest pain is common but not serious and is not necessarily ischemia
21 Contraindications to Triptans and DHE (cont’d) Known CAD or CVDUncontrolled hypertensionPregnancyHemiplegic or basilar migraineWithin 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 positiveDiagnosed with “migraine with aura”
23 Case Conclusion (cont’d) Pregnancy reduces migraines in most patients but may get worseTriptan and DHE contraindicated since she is pregnantTreated 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 givenDischarged home with OB folllow up.