What is the appropriate emergency department workup for a 26-year-old female with daily headaches for 2 months that have acutely worsened?

Emergency Department Workup for a 26-Year-Old Female with Daily Headaches for 2 Months with Acute Worsening

The emergency department workup for a 26-year-old female with daily headaches for 2 months that have acutely worsened should include a thorough assessment for "red flags" suggesting secondary headache causes, followed by appropriate neuroimaging if indicated, while also providing symptomatic treatment. 1

Initial Assessment for Red Flags

• Evaluate for sudden onset/thunderclap headache, which may indicate subarachnoid hemorrhage 1
• Assess for headache that worsens when lying down or bending over, which may suggest increased intracranial pressure 1
• Check for neurological deficits, which may indicate stroke, hemorrhage, or mass lesion 1
• Determine if headache is worsened by Valsalva maneuver, which increases suspicion for secondary causes 2
• Note if headache awakens the patient from sleep, is of new onset in an older person, or is progressively worsening, which are concerning features 2
• Evaluate for fever and meningeal signs, which may indicate infectious causes 3

Neuroimaging Considerations

• Neuroimaging should be considered in this patient with nonacute headache that has worsened and persisted for 2 months 2
• Non-contrast head CT is the first-line imaging study in the emergency department setting 1
• MRI of the brain is preferred for less urgent cases and provides better evaluation of headaches with concerning features 3
• If the headache has atypical features or does not meet the strict definition of migraine, a lower threshold for neuroimaging should be applied 2

Laboratory Studies

• Complete blood count (CBC) to evaluate for signs of infection or abnormal platelets 1
• Basic metabolic panel to assess for electrolyte abnormalities 1
• Consider coagulation studies if there are concerns for coagulopathy 1
• If fever or meningeal signs are present, lumbar puncture may be indicated after neuroimaging 3

Diagnostic Considerations

• Consider chronic migraine diagnosis if patient has ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria 2
• Medication overuse headache should be considered, defined as headache occurring on 15 or more days per month for at least 3 months due to overuse of acute medication 2
• The threshold for medication overuse headache varies by treatment (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 2
• Only 20% of patients who fulfill criteria for chronic migraine are correctly diagnosed, highlighting the importance of careful assessment 2

Treatment Approach

• For acute treatment in the ED, consider NSAIDs, acetaminophen, or combination therapy for mild headache 2
• For moderate to severe headache, consider triptans (sumatriptan 50-100 mg) if no contraindications exist 2, 4
• Triptans should be avoided in patients with cardiovascular disease due to vasoconstrictive properties 5
• Consider antiemetics like metoclopramide or prochlorperazine for accompanying nausea and as adjunctive therapy for pain 2
• Avoid opioids and butalbital for treatment of acute headache 2
• If the patient has frequent headaches, consider initiating preventive therapy 2

Follow-up Recommendations

• Advise the patient to maintain a headache diary to track frequency, severity, and medication use 2
• Recommend lifestyle modifications including hydration, regular meals, sufficient sleep, physical activity, and stress management 2
• Consider referral to neurology or headache specialist for ongoing management, especially if diagnosis of chronic migraine is suspected 2
• Educate about medication overuse headache and the importance of limiting acute medications 2

Common Pitfalls to Avoid

• Failing to recognize red flags that suggest secondary headache disorders 1, 6
• Overuse of neuroimaging in patients with typical features of primary headache and normal neurological examination 2
• Using opioids for headache management, which can lead to dependency, rebound headaches, and loss of efficacy 2
• Not considering medication overuse as a potential cause of chronic daily headache 2
• Missing the diagnosis of chronic migraine, which occurs in approximately 80% of patients who meet criteria 2