From the Guidelines
For a patient complaining of headache in the hospital, I would first assess the headache characteristics and vital signs to rule out dangerous causes, and consider initial treatment options such as acetaminophen or ibuprofen, with migraine-specific treatments and non-pharmacological approaches as needed, as recommended by the most recent guidelines 1. When evaluating a patient with a headache, it's essential to consider the potential causes, including primary headache disorders like migraine, cluster, and tension-type headaches, as well as secondary headaches with underlying pathologic causes 1. Key steps in management include:
- Assessing headache characteristics and vital signs to rule out dangerous causes
- Considering initial treatment options such as:
- Acetaminophen 650-1000mg every 6 hours or ibuprofen 400-600mg every 6 hours if not contraindicated
- Ketorolac 15-30mg IV/IM or tramadol 50-100mg every 6 hours for moderate to severe pain
- Migraine-specific treatments like sumatriptan 6mg subcutaneously or 50-100mg orally, metoclopramide 10mg IV with diphenhydramine 25mg IV, or prochlorperazine 10mg IV
- Non-pharmacological approaches, including:
- Darkening the room
- Reducing noise
- Applying cold compresses
- Ensuring adequate hydration It's crucial to investigate underlying causes, such as medication side effects, caffeine withdrawal, dehydration, or more serious conditions like meningitis, stroke, or intracranial hemorrhage, especially if the headache is sudden, severe, or accompanied by neurological symptoms, fever, or neck stiffness, as highlighted in guidelines for the management of aneurysmal subarachnoid hemorrhage 1. Regular reassessment of pain and response to treatment is essential for appropriate management, and consultation with neurology may be necessary for severe, intractable headaches.
From the Research
Evaluation of Headache
To evaluate a patient complaining of headache, the following steps can be taken:
- Take a thorough history and physical examination to differentiate primary headaches from secondary headaches 2, 3, 4, 5
- Identify red flag signs and symptoms, such as focal neurologic signs, papilledema, neck stiffness, and sudden onset of the worst headache in the patient's life, which may indicate serious underlying pathology 2, 5
- Consider the patient's age, medical history, and presence of cancer or immunosuppression when evaluating the headache 3, 5
Diagnostic Tests
The following diagnostic tests may be considered:
- Neuroimaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), to evaluate for secondary causes of headache, such as intracranial hemorrhage or neoplasm 2, 6
- Lumbar puncture, if suspected of having an infection or other condition that requires cerebrospinal fluid analysis 2
Treatment Options
The following treatment options are available:
- Acute migraine treatment, including acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine 3
- Migraine-specific treatments, such as triptans, gepants, and lasmiditan, for patients who do not respond to initial treatment 3
- Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, for patients with frequent headaches 3, 4
- Behavioral strategies, such as avoiding medication overuse and maintaining a headache diary, to help manage headache frequency and severity 4
Special Considerations
The following special considerations should be taken into account:
- Avoiding opioids for headache treatment, as they can lead to medication overuse headaches 4
- Being cautious when prescribing triptans to patients with cardiovascular disease, due to their vasoconstrictive properties 3
- Considering the patient's individual needs and medical history when selecting a treatment plan 3, 4