You have a new patient!
A 60-year-old male is brought to the Emergency Room by a family who gives a history of sudden onset severe headache with vomiting and right-sided weakness. The symptoms began one hour ago. He is a known diabetic on Metformin and has been hypertensive on Losartan for the past 20 years. The patient has poor compliance with his home medications. The family denies any history of trauma, seizures, or antiplatelet or anticoagulation drug intake.
On examination, the patient is unresponsive with HR -98/min, BP: 210/120 mmHg, RR: 16/min, oxygen saturation: 80% room air, and temperature: afebrile. The GCS is 5 (E1V1M3), and the patient has right-sided weakness 0/5, absent deep tendon reflexes, glucose is 198mg/dl, and pupils are bilaterally midsized, equal, and reactive to light.
What do you need to know?
Headache is a common complaint in the Emergency Room (ER). It constitutes 1 – 4 % of all ER visits [1]. The true global prevalence of headache is unknown because the pathophysiology and causes of headache are broad. Headache disorders collectively constitute the seventh highest cause of years lived with disability (YLDS) [2].
Headaches are classified as primary headache disorders (when pain is the disease) and secondary headache disorders (when headache is a symptom of another disease). Primary headache disorders include migraine, tension headache, and cluster headache. Secondary headache disorders are listed below in Table 1.
Table 1 – Secondary headache disorders
Pathology | Examples |
Headache attributed to head or neck trauma | Post-traumatic headache Concussion |
Headache attributed to cervical or cranial vascular disorders | Subarachnoid hemorrhage Intraparenchymal hemorrhage Subdural or epidural hematoma Cavernous/venous sinus thrombosis Arteriovenous malformation Temporal arteritis Carotid/vertebral artery dissection |
CNS infections | Meningitis Encephalitis Cerebral abscess |
Intracranial non vascular space occupying lesions | Tumors Parasitic or inflammatory lesions |
Headache attributed to substance or withdrawal | Nitrates and nitrites Mono amine oxidase inhibitors Alcohol withdrawal Abuse of analgesics |
Headache or facial pain due to head, ears, eyes, nose, or throat disorders | Glaucoma Sinusitis Optic neuritis Iritis |
Headache attributed to altered homeostasis | Fasting headache High altitude cerebral edema Hypoxia Hypercarbia Hypothyroidism Obstructive sleep apnea |
Miscellaneous causes | Preeclampsia Post dural puncture headache |
Most patients presenting to the ER with headache have a primary headache disorder, with migraine being the most common [3]. However, it is vital to evaluate for headache signs and symptoms that point towards secondary causes. The SNNOOP 10 list in Table 2 reviews important red flag signs and symptoms to consider in a patient with headache [4].
Table 2 – Red flag signs and symptoms of headache (SNNOOP 10 list)
Sign or symptom | Related secondary headache cause |
Systemic symptoms including fever | Headache attributed to infection or nonvascular intracranial disorders, like carcinoid or pheochromocytoma |
Neoplasm in history | Neoplasms of the brain, metastasis |
Neurologic deficit or dysfunction (including decreased consciousness) | Headaches attributed to vascular, nonvascular intracranial disorders; brain abscess and other infections |
Onset of headache is sudden or abrupt | Subarachnoid hemorrhage and other headaches attributed to cranial or cervical vascular disorders |
Older age (after 50 years) | Giant cell arteritis and other headache attributed to cranial or cervical vascular disorders; neoplasms and other nonvascular intracranial disorders |
Pattern change or recent onset of headache | Neoplasms, headaches attributed to vascular, nonvascular intracranial disorders |
Positional headache | Intracranial hypertension or hypotension |
Precipitated by sneezing, coughing, or exercise | Posterior fossa malformations; Chiari malformation |
Papilledema | Neoplasms and other nonvascular intracranial disorders; intracranial hypertension |
Progressive headache and atypical presentations | Neoplasms and other nonvascular intracranial disorders |
Pregnancy or postpartum | Headaches attributed to cranial or cervical vascular disorders; post dural puncture headache; hypertension-related disorders (e.g., preeclampsia); cerebral sinus thrombosis; hypothyroidism; anemia; diabetes |
Painful eye with autonomic features | Pathology in posterior fossa, pituitary region, or cavernous sinus; Tolosa-Hunt syndrome; ophthalmic causes |
Posttraumatic onset of headache | Acute and chronic posttraumatic headache; subdural hematoma and other headache attributed to vascular disorders |
Pathology of the immune system such as HIV | Opportunistic infections |
Painkiller overuse or new drug at onset of headache | Medication overuse headache; drug incompatibility |
Primary Headache Disorders
Migraine
Migraines are one of the most common primary headache disorders. Migraines affect females more than males and are more common in the third and fourth decade of life. The clinical presentation includes unilateral or bilateral pulsating pains with moderate to severe intensity. Migraines may have associated auras, photophobia, phonophobia, blurred vision, lightheadedness, vertigo, nausea, and vomiting. Most patients seek dark, quiet rooms. The triggers for migraines include sleep deprivation, hunger, hormonal changes during menstruation, and certain medications (e.g., nitrates and oral contraceptive pills) [5].
Cluster Headache
Cluster headaches occur suddenly, last 15 minutes to 3 hours in duration, and tend to occur repeatedly during a defined time interval. This type of headache is more common in men than women. Precipitating factors include ingestion of alcohol, stress, and climate change. The headache begins as unilateral sharp stabbing pain in the eye, exclusively in the trigeminal territory, accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, forehead, and facial swelling [5].
Tension Headache
Tension headaches, like migraines, are a common cause of primary headaches and affect women more than men. Tension headaches may last from minutes to days. Physical examination reveals tender areas on the scalp and neck. Patients complain of a tight, band-like discomfort around the head that is non pulsating and dull in nature. The headache does not worsen with physical activity. Anxiety and depression may coexist with chronic tension type headaches [6].
Secondary Headache Disorders
There are various secondary causes of headaches, ranging from benign to severe. This section will focus on a small list of etiologies relevant to the emergency medicine practitioner.
Subarachnoid Hemorrhage (SAH)
SAH is a life-threatening cause of headache that should be considered in all ER patients with headache. Accumulation of blood in the subarachnoid space activates meningeal nociceptors, causing headache and meningismus. Causes for non-traumatic SAH include ruptured saccular aneurysms, arteriovenous malformations, cavernous angiomas, and coagulopathy. The risk of brain aneurysmal rupture increases with age, hypertension, smoking, excessive alcohol consumption, and use of sympathomimetic drugs [7].
Patients with SAH historically present with a severe, acute onset headache that is maximal intensity at onset (thunderclap headache). The onset of headache may be spontaneous or after physical exertion. Associated signs and symptoms are nausea, vomiting, neck stiffness, photophobia, seizures, depressed consciousness, and focal neurological abnormalities. Retinal hemorrhage may be present on fundoscopic examination. SAH patient prognosis can be predicted with the Hunt and Hess classification system [7], as shown in Table 3.
Table 3 – Hunt and Hess classification of cerebral aneurysms and subarachnoid hemorrhage
Grade | Condition |
0 | Unruptured aneurysm |
1 | Asymptomatic or minimal headache and slight nuchal rigidity |
2 | Moderate or severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy |
3 | Drowsiness, confusion or mild focal deficit |
4 | Stupor, moderate to severe hemiparesis |
5 | Deep coma, decerebrate posturing, moribund appearance |
- Grades 1 or 2 – good prognosis
- Grade 3 – moderate prognosis
- Grades 4 or 5 – poor prognosis
Intracranial Neoplasms
Headache is a common presenting symptom of patients with a brain tumor, but the symptoms are variable. Symptoms depend on the site of tumor, traction on meninges or large vessels, increase in intracranial pressure, or hydrocephalus. Other than headache, patients may have sleep disturbances, nausea and vomiting, seizures, focal neurologic deficits, alterations in consciousness, personality disorders, and cognitive difficulties [8].
Meningitis
Acute bacterial meningitis may present with headache, fever, nuchal rigidity, nausea, vomiting, photophobia, new skin rash, seizures, focal neurologic deficits, or alterations in consciousness. The most common pathogens causing bacterial meningitis in adults are Streptococcus pneumoniae and Neisseria meningitidis. Bacterial meningeal invasion occurs when bacteria colonize host mucosal epithelium, invade and survive within the bloodstream, cross the blood-brain barrier, and multiply within the CSF. Once inflammation is initiated, a series of injuries occur to the endothelium of the blood-brain barrier that result in vasogenic brain edema, loss of cerebrovascular autoregulation, and increased intracranial pressure. This results in localized areas of brain ischemia, cytotoxic injury, and neuronal death [9].
Giant Cell Arteritis (GCA, or Temporal arteritis)
GCA is an inflammatory vasculopathy affecting mainly the extracranial branches of the carotid artery (temporal and occipital). The common features of giant cell arteritis are advanced age, female gender, headache, visual symptoms, jaw claudication, temporal artery tenderness, and systemic symptoms (e.g., fever, weight loss, fatigue). One of the most serious complications of GCA is blindness, but a range of visual symptoms and signs may occur, such as diplopia, visual field deficits, amaurosis fugax, or an afferent pupillary defect. Typical GCA headaches are worse in the morning than later in the day and can be constant or intermittent. Other complications include transient ischemic attacks, peripheral neuropathies, and stroke. Palpation of the temporal artery may reveal absent pulses, erythema, and nodular swellings [10].
Carotid and Vertebral Artery Dissection
The classic symptoms of carotid artery dissection include:
- Unilateral headache or neck pain.
- Ipsilateral partial Horner’s syndrome.
- Blindness (dissection into retinal artery).
- Contralateral motor deficits.
Vertebral artery dissection may also present with severe unilateral headache or neck pain. Dissection along the vertebral artery may result in brainstem or cerebellar ischemia, causing vertigo, vomiting, diplopia, ataxia, tinnitus, unilateral facial weakness, alterations in consciousness, or cranial nerve deficits.
Both carotid and vertebral artery dissection should be considered in a patient presenting with headache or neck pain with a history of recent head or neck trauma, sudden neck movement, neck torsion, coughing, chiropractic manipulation, minor falls, weight lifting, basketball, volleyball, or a motor vehicle collision [11].
Cerebral Vein Thrombosis (CVT)
Patients with this diagnosis often have a headache lasting days to weeks, along with other signs and symptoms, like seizures, focal neurologic deficits, orbital pain, proptosis, chemosis, and papilledema. Symptoms are due to raised intracranial pressure from occlusion of the cerebral venous system, causing ischemia, infarction, or hemorrhage.
Major risk factors for CVT include pregnancy, post-partum state, malignancy, head trauma, recent surgery, parameningeal infections, oral contraceptives, history of vasculitis, inflammatory bowel disease, and connective tissue disease [12].
Initial Assessment and Stabilization (ABCDE approach)
When a patient presents with headache to the ER, it is vital to follow the ABCDE sequence of initial assessment.
- Airway: look for airway patency. Assess if the patient is talking normally or if there are signs of airway obstruction or aspiration. Patients with SAH, intraparenchymal bleed, CVT, or recent seizure may have airway compromise due to poor GCS. These patients may require interventions, such as manual opening of the airway with a head-tilt-chin lift or jaw thrust maneuver, insertion of an oropharyngeal or nasopharyngeal airway, or suctioning of secretions or vomitus from the airway. Patients with GCS under 8 should be considered for supraglottic airway insertion or endotracheal intubation.
- Breathing: look for tachypnea or bradypnea, changes to oxygen saturation, and abnormal breath sounds. Intracranial bleeds or mass lesions may influence the central respiratory center, causing decreased, abnormal, or absent respirations [7]. Administer supplemental oxygen for hypoxia. Consider oxygen via face mask, positive pressure bag valve mask ventilation, or intubation, based on respiratory effort, GCS, and concern for aspiration.
- Circulation: check the heart rate, blood pressure, peripheral and central pulses, and capillary refill time. Severe hypertension with headache and altered mentation should raise concern for intracranial bleeding [7]. Headache with severe hypertension in a pregnant patient should raise concern for pre-eclampsia or eclampsia. Fever with headache should raise concern for infectious conditions, like meningitis or encephalitis. Intravenous antihypertensive medications should be initiated during this step if needed. Monitor for bradycardia, hypertension, and abnormal breathing, which can indicate impending brain herniation from elevated intracranial pressure.
- Disability: check pupillary size and reactivity, calculate a Glasgow coma score, and check a glucose level. Perform a focused neurological examination with assessment of the cranial nerves, sensory and motor function, and cerebellar signs. Patients with complex migraine headaches may exhibit photophobia, diplopia, paresthesias, dysarthria, tinnitus, or vertigo. Patients with stroke, intraparenchymal bleeding, subarachnoid hemorrhage, CVT, carotid or vertebral artery dissection, intracranial space-occupying lesions, and encephalitis may present with focal neurological deficits and varying levels of GCS [7,8].
- Exposure: Fully undress your patient and perform a head-to-toe examination. Any signs of head trauma, including headache, should raise suspicion for intracranial bleeding. Petechiae and purpura on the skin may point towards infective pathologies, like septicemia or meningococcal meningitis [13].
Medical History
A detailed history in a patient with headaches can provide clues to the cause. Ask your patient about the time of symptom onset, pain location, headache characteristics, and associated symptoms. Ask about past medical history, surgical history, relevant family history, and drug or alcohol use.
- Time of onset: sudden onset symptoms may be seen in subarachnoid hemorrhage, ischemic or hemorrhagic strokes, or carotid artery dissection. Gradual onset of symptoms is more common in migraine, cluster headache, tension headache, headaches due to infective pathology, and CVT [5,6].
- Site of headache: Most migraine and cluster headaches present with unilateral pain with cluster headache involving branches of the trigeminal nerve (around orbit). Tension headaches present more often as bilateral head pain. Sinus headaches have pain behind the maxillary and frontal sinuses [5,6].
- Characteristics and associated symptoms: Migraines are associated with auras, photophobia, phonophobia, blurred vision, lightheadedness, nausea, or vomiting [5]. Cluster headaches may have ipsilateral autonomic symptoms, such as ptosis, miosis, eye tearing, or facial swelling [5]. Tension headaches may present with tender areas on the scalp and neck [6]. Ask about associated symptoms for secondary headaches, like fever and neck stiffness (meningitis), vision changes (acute glaucoma, giant cell arteritis), new seizures, vomiting, or focal motor or sensory changes (space-occupying lesion, intracranial bleeding, CVT, etc.) [8-10,12].
- Risk factors:
- Intraparenchymal Bleeding: hypertension, smoking, alcohol abuse, anticoagulation medication usage, recent head trauma [3,7].
- Subarachnoid Bleeding: hypertension, smoking, cocaine use, family history of brain aneurysms in close relatives, polycystic kidney disease, Marfan syndrome, Ehlers-Danlos syndrome [7].
- Carotid Artery Dissection: recent neck trauma, recent neck torsion during sporting activities or medical treatments (e.g., chiropractic maneuvers) [11]
- Cerebral Venous Thrombosis: pregnancy, recently postpartum, oral contraceptive use, hypercoagulable conditions (thrombophilias, antithrombin III, protein C and S deficiency, factor V Leiden mutation, antiphospholipid syndrome, malignancy), recent surgery [12].
- Post Dural Puncture Headache: recent lumbar puncture
Physical Examination
Patients presenting with headache should undergo a thorough head-to-toe physical exam after the ABCDE assessment. Special care should be taken in examining the head, ears, eyes, neck, and throat, as well as in performing a focused neurological exam. The neurological exam should include calculating a Glasgow coma score, cranial nerve testing, assessment of motor and sensory deficits in the extremities, and assessment of gait and coordination. A full set of vitals, including a temperature and glucose level, should be taken.
When To Ask Your Senior for Help
If you are immediately concerned about a life-threatening condition, or if the patient needs any interventions during the ABCDE assessment, you should notify a supervising doctor.
Patient details that should trigger you to alert your senior:
- Inability to talk or
- Altered breathing pattern or use of accessory muscles of respiration
- Severe hypertension, hypotension, or hypoxia
- Asymmetric pupillary sizes
- Severe headache with acute onset
- Signs of meningeal irritation or raised intracranial pressure
Not-To-Miss Diagnoses
Headaches have many causes. As an emergency medicine provider, it is important not to miss certain diagnoses that have a high rate of morbidity or mortality. Some diagnoses to always consider in the patient with headache are intraparenchymal bleeding, subarachnoid bleeding, giant cell arteritis, acute glaucoma, meningitis, encephalitis, cerebral vein thrombosis, carotid and vertebral artery dissection, brain malignancy, and pre-eclampsia.
Acing Diagnostic Testing
The investigations you order for your headache patient will depend on your history, physical exam, and top conditions on your differential diagnosis list.
Some investigations to consider in headache patients:
- Glucose testing should be ordered in any patient with headache plus altered mental status, focal neurologic deficits, or seizures.
- Urine pregnancy testing should be ordered for any female of child-bearing age presenting with headache.
- ECG abnormalities in the form of arrhythmias and non-specific ST-T wave changes can be seen in patients with intracranial bleeding or space-occupying lesions
- Complete blood count can help support infective etiologies if leukocytosis is present.
- Serum chemistry is used to evaluate for any electrolyte abnormalities in patients with new seizures or vomiting.
- ESR or CRP is considered if you are concerned about Giant cell arteritis [10]
- HIV testing is considered based on the history and physical exam if there are clinical signs of immunocompromise
- CT or MRI imaging is often unnecessary in a patient with a primary headache. It should be ordered based on patient history and physical exam, particularly with concerns for SAH, intracranial bleeding, or a space-occupying lesion should have non-contrast CT brain imaging [7,8]. Patients with concerns for carotid or vertebral artery dissection should have a CT angiogram of the neck and head [11]. Patients with concerns for cerebral venous thrombosis should have an MR venogram or CT venogram [12].
Examples of CT images of patients with conditions that may present with headache are below.
Figure 1a (left) and Figure 1b (right): Subarachnoid bleed on CT brain without contrast. Acute bleeding is demonstrated as a bright white (radio-opaque) substance. The distribution of blood seen in Figure 1a is sometimes termed the “starfish of death.”
Empiric and Symptomatic Treatment
Medications for symptom control should be considered for any patient with headache and other associated symptoms. Table 4 below lists some common medications to consider for migraine headaches.
Table 4- Medications for migraine headaches
Drug | Dose | Comments |
Acetaminophen | 500 – 1000 mg PO every 6hrs | Safe in pregnancy |
Ibuprofen | 600 -800 mg PO every 6hrs | Can cause GI upset Avoid in pregnancy Caution in patients with renal insufficiency |
Ketorolac | 15-30 mg IV or IM every 6hrs | Same as ibuprofen |
Metoclopramide | 10 mg IV or IM every 6hrs | Administer slowly to avoid extrapyramidal symptoms |
Diphenhydramine | 25-50 mg IV or IM every 6hrs | May cause drowsiness |
Dihydroergotamine | 1 mg IV or IM Maximum 3mg/24hours | Contraindicated in pregnancy, uncontrolled HTN, or coronary artery disease |
Sumatriptan | 6 mg SC injection x 1 (max 12mg SC/24hrs) | Same as Dihydroergotamine |
Basic analgesics, like acetaminophen or NSAIDs, are first-line treatments for tension headaches [6]. High-flow oxygen therapy via a non-rebreather mask at 12-15 liters/min is the first-line treatment for cluster headaches [5].
Patients with signs and symptoms of elevated intracranial pressure (e.g., asymmetric pupil size, depressed GCS, vomiting, etc.), brain edema on CT imaging, or impending herniation on CT imaging should receive IV mannitol, IV 3% NaCl, or IV steroids, in consultation with a neurosurgical specialist [8]. High-dose IV steroids are also used in patients with giant cell arteritis [10].
There is no role for routine prophylactic antiepileptic medications in patients with headache and most types of intracranial bleeding. However, antiepileptics, like Levetiracetam, are generally well tolerated and are sometimes recommended by neurosurgical specialists for seizure prevention. For most patients with headache and seizure, IV benzodiazepines should be first-line for seizure treatment. One exception is eclampsia, where IV magnesium is the preferred therapy.
Anticoagulation, such as IV unfractionated heparin, should be administered in patients with cerebral venous thrombosis and for extracranial carotid or vertebral artery dissection [11]. Patients presenting with headache and signs of ischemic stroke may be candidates for thrombolysis with IV Alteplase or Tenecteplase, depending on local resources and the time since symptom onset. IV antibiotics should be administered empirically for patients with headache with suspected meningitis or encephalitis [3,9].
Procedures
Lumbar Puncture [14]
- Indications for the procedure: CSF collection with a lumbar puncture can help to evaluate for a CNS infection, such as meningitis. This procedure can also assist in assessing for subarachnoid hemorrhage. CT head is highly sensitive in detecting SAH in the first 6 hours after headache onset, but the sensitivity diminishes beyond hour 6. A lumbar puncture can be considered in a patient with deep clinical concern for SAH and a negative CT scan with symptoms over 6 hours [7].
- Contraindications: Raised intracranial pressure (e.g., brain mass or intracranial bleeding with midline shift on CT), coagulopathy, or trauma or infection at the site of needle insertion
- Complications: Bleeding, infection, post-dural puncture headache, pain during the procedure
Before the procedure:
- Explain the procedure, obtain consent, and gather materials (Figure 6) to maintain aseptic precautions.
- Place the patient in the lateral decubitus or seated position.
- Identify the highest points of iliac crests bilaterally.
The equipment needed for a lumbar puncture procedure includes a sterile lumbar puncture tray, which typically contains a spinal needle with stylet (commonly 20G–22G), local anesthetic (e.g., lidocaine), antiseptic solution (e.g., povidone-iodine or chlorhexidine), sterile gloves, drapes, and gauze. Additionally, a manometer with tubing is required for measuring cerebrospinal fluid (CSF) pressure, along with collection tubes for CSF sampling. Optional items may include a face mask, eye protection, and an assistant for patient positioning and monitoring.
To identify the L4 interspace for a lumbar puncture (Figure 7), start by positioning the patient appropriately—either sitting and leaning forward or lying in the lateral decubitus position with knees drawn to the chest and the back flexed to maximize exposure of the vertebral spaces. Palpate the iliac crests on both sides, noting their highest points. Draw an imaginary line connecting these points, known as the intercristal or Tuffier’s line, which usually crosses the spinous process of the L4 vertebra. The L4-L5 interspace is located just below this line. Confirm the space by palpating the spinous processes to ensure accurate identification before proceeding.
This level corresponds to L4-L5 intervertebral space where the spinal needle should be inserted. Instruct the patient to arch their spine posteriorly to open the interspinous spaces. Clean and drape the area. Administer local anesthesia to the planned site of the procedure. Prepare four marked containers to collect the CSF. Using aseptic technique, advance the spinal needle at the L4-L5 interspace until a popping sensation is felt and CSF drips from the spinal needle. Measure CSF opening pressure by connecting a manometer as soon as fluid appears and note the reading. Collect about 1 mL of CSF in all 4 marked containers in a consecutive fashion (Figure 8). Once sufficient CSF is collected, place the stylet back in the needle, remove the spinal needle, and cover the site with gauze or a Band-Aid. Send the CSF to the laboratory for analysis, re-evaluate your patient, and provide advice regarding puncture headache [14].
The chart below describes how CSF is interpreted by the clinician once it is analyzed by the laboratory.
Table 5 – CSF interpretation [15]
Normal | Bacterial Meningitis | Viral Meningitis | Subarachnoid Hemorrhage | |
Opening pressure (mmHg) | 7-18 | >30 | Normal | Increased |
Appearance | Clear, colorless | Turbid | Clear | Xanthochromia present |
Protein (mg/dl) | 23-38 | Increased | Normal to decreased | Increased |
Glucose | 2/3rd of serum glucose | Decreased | Normal | Normal |
Gram stain | Negative | Positive | Negative | Negative |
WBC count | <5 cells | Predominantly neutrophils | Predominantly lymphocytes | May be increased due to bleeding |
Special Patient Groups
Pregnant Patients
Pregnant patients with headache are at increased risk for some diagnoses more than nonpregnant women due to pregnancy being a hypercoagulable state. Pregnant patients with headaches are unable to receive all the same medications as nonpregnant patients. Headache medications that are safe in pregnancy are paracetamol, metoclopramide, diphenhydramine, magnesium, and opioids for severe pain. Drugs to avoid during pregnancy include ergotamine, NSAIDS, valproate, lithium, and topiramate [16]. Specific causes of headache to consider in pregnancy are pre-eclampsia, eclampsia, cerebral venous thrombosis, and stroke. Treatment of headache should primarily focus on the cause [16].
Children
Headache is a common cause of ED visits in the pediatric population [17]. The causes of headaches in the pediatric population range from more benign primary headache etiologies to more secondary severe etiologies. CT imaging should be limited to cases where more serious signs and symptoms are present, such as change in behavior, confusion, unexplained vomiting, unexplained high fevers, head trauma, or focal neurologic deficits [17]. Medications for pediatric headaches are weight-based in their dosing. The standard pediatric dose for ibuprofen is 10 mg per kilogram (mg/kg) of body weight per dose. This dosage can be administered every 6 to 8 hours as needed, with a maximum of three doses in a 24-hour period. It’s important not to exceed a total daily dose of 40 mg/kg or 1,200 mg, whichever is less. For acetaminophen, the recommended pediatric dose ranges from 10 to 15 mg/kg per dose. This can be given every 4 to 6 hours as needed, with a maximum of five doses in 24 hours. The total daily dose should not exceed 75 mg/kg or 3,000 mg, whichever is less.
Elderly
Elderly patients experiencing headaches may have additional health conditions that raise the risk of serious underlying causes, such as a history of hypertension, cancer, previous brain surgeries, stroke, or the use of anticoagulant medications. When evaluating and treating these patients, it’s important to tailor your approach based on the suspected diagnosis. However, it is advisable to have a lower threshold for ordering diagnostic tests in elderly patients with unexplained headaches.
When To Admit
Primary headache disorders, like migraine, cluster headache and tension headaches, do not require admission and should be treated symptomatically in the ER. Upon discharge, these patients should be advised to have adequate sleep, stay hydrated, consume regular meals, and avoid any headache triggers. Patients with a headache secondary to a dangerous etiology, such as meningitis or intracranial bleeding, should be admitted for further treatment and monitoring. Patients with red flag signs or symptoms of a dangerous etiology should also be admitted for further management, even without a confirmed diagnosis.
Revisiting Our Patient
You return to your 60-year-old male patient with sudden onset headache and right-sided weakness. You note his severe hypertension, hypoxemia, right-sided motor deficits, and low GCS.
You follow your ABCDE approach to be sure not to miss any critical steps in management.
- Airway: This patient has a depressed mental status and no gag reflex. You notice some secretions in his airway and prepare for intubation.
- Breathing: His lungs are bilaterally clear and equal. After his airway is suctioned, you apply supplemental oxygen via a non-rebreather mask.
After the patient is intubated, you continue your assessment.
- Circulation: The patient continues to be hypertensive to 210/120 mmHg after intubation. You administer IV labetalol 10mg and begin a fentanyl infusion for sedation.
- Disability: The glucose is 198mg/dL. Your initial brief exam demonstrated right-sided motor deficits and normal mid-sized pupils.
- Exposure: There are no physical signs of trauma or rashes on the exam
Once the patient is stabilized, he receives a CT head without contrast, showing an acute subarachnoid bleed. Basic pre-operative laboratory tests are drawn and you contact the neurosurgeon on call. The neurosurgery team recommends strict blood pressure control and admission to the ICU for operative management. You explain the diagnosis and plan of care to the patient’s family with understanding and agreement.
Author
Shailaja Sampangi Ramaiah
Dr. Shailaja Sampangi Ramaiah is a Professor and Head of Emergency Medicine at Father Muller Medical College, Mangalore, India. With advanced qualifications in anesthesia and medical education, she is a FAIMER fellow and ACME-certified educator. Dr. Shailaja leads initiatives in simulation training and clinical quality improvement and is a life member of several prestigious medical associations. She is passionate about advancing emergency care education.
Listen to the chapter
References
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Reviewed and Edited By
Joseph Ciano, DO, MPH, MS
Dr. Ciano is a board-certified attending emergency medicine physician from New York, USA. He works in the Department of Emergency Medicine and Global Health at the Hospital of the University of Pennsylvania. Dr. Ciano’s global work focuses on capacity building and medical education and training in low-middle income countries. He is thrilled to collaborate with the iEM Education Project in creating free educational content for medical trainees and physicians.
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
