From the Guidelines
The emergency department headache algorithm should prioritize rapid assessment for life-threatening causes, followed by evaluation for red flags, and then provide appropriate analgesia based on severity, with the addition of a triptan to a nonsteroidal anti-inflammatory drug for moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to a nonsteroidal anti-inflammatory drug, as recommended by the American College of Physicians 1.
Key Steps in the Algorithm
- Evaluate for red flags including sudden onset, "worst headache of life," fever, altered mental status, focal neurological deficits, or immunocompromised status
- Obtain immediate neuroimaging (CT head without contrast) and consider lumbar puncture to rule out subarachnoid hemorrhage, meningitis, encephalitis, or mass lesion if red flags are present
- Provide appropriate analgesia based on severity, with options including:
- NSAIDs like ibuprofen 400-600mg or naproxen 500mg for mild to moderate pain
- Combination therapy with metoclopramide 10mg IV plus diphenhydramine 25mg IV to prevent akathisia, or prochlorperazine 10mg IV for severe pain
- Sumatriptan 6mg subcutaneous or 100mg oral for migraine, if no contraindications exist
Additional Considerations
- Consider dexamethasone 10mg IV as adjunct therapy to prevent recurrence in status migrainosus
- Provide intravenous fluids if dehydration is present
- Discharge patients with appropriate follow-up instructions, including when to return (worsening symptoms, new neurological deficits), and outpatient referral for recurrent headaches The American College of Physicians recommends the addition of a triptan to a nonsteroidal anti-inflammatory drug for moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to a nonsteroidal anti-inflammatory drug, based on moderate-certainty evidence 1. This approach prioritizes both the immediate concern of providing symptomatic relief and the long-term goal of preventing unnecessary return visits and improving quality of life.
From the Research
Emergency Department Headache Algorithm
The emergency department headache algorithm involves several steps to evaluate and manage patients presenting with acute headache.
- The first step is to take a detailed history of the current headache, focusing on dynamics, phenotype, and trigger factors, as well as any preexisting headache 2.
- "Red flags" should be specifically interrogated to identify potential secondary headaches 2, 3, 4, 5.
- A physical examination, including vital signs, neurological exam, otorhinolaryngological, and ophthalmological exams, should be performed to generate hypotheses about the etiology of the headache 2.
- Imaging, laboratory, cerebral spinal fluid studies, and ultrasound may be used to test these hypotheses and rule out secondary headaches 2, 3, 4, 5.
- If a secondary headache is identified, treatment should be causal, and symptomatic treatment may also be necessary 2.
- If a secondary headache can be excluded, a primary headache diagnosis should be made, and specific therapy should be initiated 2, 3.
Treatment Options
Treatment options for patients presenting with headache in the emergency department include:
- Intravenous fluids 3
- Anti-dopaminergic agents with diphenhydramine 3
- Steroids 3
- Divalproex 3
- Nonsteroidal anti-inflammatory drugs 6, 3
- Intravenous dihydroergotamine 3
- Nerve blocks 3
- Ketamine and lidocaine may be used with limited or inconsistent evidence 3
- Opioids should be avoided due to their scarce effectiveness in the acute phase 6
Follow-up and Referral
- Patients with primary headaches should be referred to a Headache Center for further management and to prevent future emergency department visits 6, 2.
- Follow-up appointments should be scheduled to understand the development of a secondary headache and its cause 2.
- Optimizing prophylaxis and acute therapy is important to prevent future emergency department visits 2