Headache Treatment: What’s the Latest?

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

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

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

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.

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.

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

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?

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

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

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

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

“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.)

“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

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

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

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

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

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

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

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

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”

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

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

Questions?? www.ferne.org ferne@ferne.org Philip Bossart, MD philip.bossart@hsc.utah.edu ferne_2005_aaem_france_bossart_ha_fshow.ppt 8/27/2005 2:38 AM 54 54 1