What is the management approach for an adult patient with no significant past medical history presenting to the emergency department (ED) with a mid-range headache?

Management of Mid-Range Headache in the Emergency Department

Initial Priority: Rule Out Secondary Causes

The first and most critical step is to systematically evaluate for red flags indicating dangerous secondary headaches, as failure to obtain appropriate imaging is associated with 4-fold higher mortality and disability. 1

Red Flag Assessment

Immediately evaluate for these high-risk features that mandate urgent neuroimaging:

• "Worst headache of my life" - present in 80% of subarachnoid hemorrhage (SAH) cases 1
• Thunderclap onset (sudden, maximal intensity within seconds to minutes), particularly during exertion or sexual activity 1
• Age >50 years with new-onset headache 1
• Progressive worsening over days to weeks 1
• Awakens patient from sleep 1
• Worsened by Valsalva maneuver 1
• Sentinel/warning headaches occurring 2-8 weeks prior (present in 20% before major SAH rupture) 1

Focused Neurological Examination

Perform a targeted neurological assessment looking for:

• Focal neurological deficits (weakness, sensory changes, visual field defects) 1
• Altered mental status or confusion 1
• Meningeal signs (neck stiffness, photophobia with fever) 1
• Papilledema on fundoscopic examination 1

Diagnostic Algorithm for Red Flag Positive Patients

If any red flags are present, non-contrast head CT must be obtained immediately, as it has 98-100% sensitivity for SAH within the first 12 hours. 1

Post-CT Decision Tree

• If CT is negative but clinical suspicion remains high: Lumbar puncture is mandatory to detect xanthochromia and definitively rule out SAH 1
• If CT shows abnormality: Manage according to the specific pathology identified (hemorrhage, mass, stroke, etc.)

Management of Primary Headache (After Excluding Secondary Causes)

Characterization of Primary Headache

Document these specific features to guide treatment:

• Location (unilateral vs bilateral, frontal vs temporal) 1
• Duration (hours vs days) 1
• Character (throbbing vs pressure-like vs stabbing) 1
• Intensity (using numeric rating scale 0-10) 1
• Associated symptoms (nausea, vomiting, photophobia, phonophobia) 1

First-Line Pharmacological Treatment

Antidopaminergic agents demonstrate the highest efficacy and should be the primary treatment, combined with NSAIDs or acetaminophen. 2

Recommended Regimen:

• Prochlorperazine or metoclopramide (antidopaminergic agent) PLUS 2
• Ketorolac (NSAID) or acetaminophen 2
• Diphenhydramine - not for analgesia, but to reduce akathisia associated with prochlorperazine 2

Adjunctive Therapies

• Dexamethasone should be administered to reduce headache recurrence after discharge 2
• Intravenous fluids only if clinical dehydration is present (not routinely for all patients) 2
• Triptans are efficacious if no contraindications exist (avoid in cardiovascular disease, uncontrolled hypertension, hemiplegic migraine) 2

Alternative Options for Refractory Cases

• Ketamine shows promise for treatment-resistant headaches 2
• Propofol may be considered in severe refractory cases 2
• Nerve blocks (occipital or sphenopalatine ganglion) demonstrate efficacy 2

Critical Medication to Avoid

Opioids should NOT be used for migraine treatment due to poor effectiveness and high risk of medication overuse headache and dependency. 1

This is explicitly recommended against by the American College of Physicians 1, and opioids show scarce effectiveness in the acute phase 3

Assessment for Medication Overuse Headache

Before prescribing discharge medications, specifically ask about frequency of acute headache medication use, as overuse is a critical factor to identify. 1

High-Risk Patterns:

• Frequency >2 times per week increases risk of medication overuse headache 1
• High-risk medications: ergotamine, opiates, triptans, butalbital-containing compounds 1

Disposition and Discharge Planning

Most patients with primary headache are appropriate for discharge once pain improvement is achieved. 2

Mandatory Discharge Components:

• Rescue medication plan for home use if ED treatments fail 1
• Education on medication overuse prevention (avoid using acute treatments >2 days per week) 1
• Scheduled follow-up within 2-3 months with primary care or headache specialist 1
• Referral to Headache Center - lack of this referral results in high rates of ED relapse 3

Common Pitfalls to Avoid

• Failing to obtain CT when red flags present - this is the most common diagnostic error with devastating consequences 1
• Assuming dehydration without clinical evidence - IV fluids should be limited to cases of ascertained dehydration 3
• Prescribing opioids - these worsen long-term outcomes and create dependency risk 1
• Discharging without follow-up plan - this leads to repeated ED visits and poor headache control 3