What is the appropriate emergency department workup for a 19-year-old female with a one-month history of headache?

Emergency Department Workup for 19-Year-Old Female with One-Month Headache

The emergency department workup for a 19-year-old female with a one-month headache should focus on ruling out dangerous secondary causes through targeted history, physical examination, and neuroimaging when red flags are present. 1

Initial Assessment: Identifying Red Flags

Key Red Flags Requiring Immediate Evaluation:

• Thunderclap headache (sudden, severe onset)
• Focal neurological symptoms or deficits
• Fever with neck stiffness (meningitis concern)
• Headache following head trauma
• Positional aggravation of headache
• Valsalva-induced headache
• Associated symptoms like weight loss or personality changes
• Abrupt change in headache pattern 1, 2

Focused History Elements:

• Onset characteristics (sudden vs. gradual)
• Pain pattern (location, quality, severity on 0-10 scale)
• Duration and frequency
• Associated symptoms (nausea, vomiting, photophobia, phonophobia)
• Aggravating/alleviating factors
• Menstrual relationship (pure menstrual migraine consideration)
• Prior headache history
• Medication use (including over-the-counter)
• Recent trauma 1, 3

Physical Examination

Critical Components:

• Vital signs (fever may indicate infection)
• Neurological examination (mental status, cranial nerves, motor/sensory, coordination)
• Fundoscopic examination (papilledema suggests increased intracranial pressure)
• Neck examination (stiffness, Kernig's/Brudzinski's signs)
• Temporal artery palpation
• Examination for sinus tenderness 1, 2

Diagnostic Testing

Neuroimaging:

• When to image: Presence of any red flags
• Preferred modality:
  • CT without contrast for suspected intracranial hemorrhage or trauma
  • MRI with and without contrast for most other conditions
  • CT/MR angiography for suspected vascular abnormalities 1

Additional Testing Based on Clinical Suspicion:

• Lumbar puncture: If meningitis or subarachnoid hemorrhage is suspected, especially with negative CT
• Blood tests: CBC, ESR, CRP if systemic inflammation is suspected
• EEG: Only if seizure disorder is suspected 1

Management Algorithm

1. If red flags present:

   • Proceed with appropriate neuroimaging
   • Consult neurology if positive findings
   • Consider lumbar puncture if meningitis or subarachnoid hemorrhage is suspected despite negative imaging

2. If no red flags and features consistent with primary headache:

   • For suspected migraine with moderate to severe pain:
     • First-line: Combination of triptan with NSAID or acetaminophen
     • For nausea/vomiting: Consider non-oral triptan and antiemetic
   • For mild headache:
     • NSAID, acetaminophen, or combination 3, 1

3. If medication overuse headache is suspected:

   • Identify if patient is using headache medication ≥15 days/month for NSAIDs or ≥10 days/month for triptans
   • Begin appropriate withdrawal protocol 3, 1

Important Considerations

• Medication choice: Individual factors like route of administration and cost should guide specific NSAID or triptan selection 3
• Avoid opioids and butalbital for acute headache treatment 3
• Counsel on timing: Treatment should begin as soon as possible after headache onset 3
• Follow-up planning: Arrange appropriate outpatient follow-up for ongoing management 4
• Preventive therapy consideration: If headaches occur frequently (>2/week) or ≥15 days/month for >3 months 1

Common Pitfalls to Avoid

• Overlooking red flags in patients with known primary headache disorders
• Failing to recognize medication overuse headache
• Confusing migraine aura with TIA
• Missing chronic migraine diagnosis
• Neglecting to consider vestibular migraine when vertigo is present 1

Remember that while most headaches in young adults are benign primary headaches, the emergency department's primary focus must be to rule out dangerous secondary causes before proceeding with symptomatic treatment.