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 the most recent guidelines for diagnosis and management of migraine and other headache disorders, as outlined in the 2021 study published in Nature Reviews Neurology 1.
Initial Assessment and Treatment Options
The initial assessment should include a thorough medical history, physical examination, and consideration of red flags such as sudden onset, "worst headache of life," fever, altered mental status, or neurological deficits. Initial treatment options may include:
- Acetaminophen 650-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours if not contraindicated
- Combination therapy with acetaminophen plus an NSAID, or addition of tramadol 50-100mg every 6 hours for moderate to severe pain
- Stronger options like hydrocodone/acetaminophen 5/325mg every 4-6 hours or morphine 2-4mg IV for breakthrough pain
Non-Pharmacological Approaches
Non-pharmacological approaches may include:
- Ensuring adequate hydration
- Providing a quiet, dark environment
- Applying cold compresses
- Addressing potential triggers like caffeine withdrawal
Importance of Monitoring and Further Evaluation
It is crucial to monitor for red flags and consider further evaluation, including neurological examination, imaging, and possible lumbar puncture, to rule out serious conditions like meningitis, subarachnoid hemorrhage, or increased intracranial pressure, as recommended in the 2021 study published in Nature Reviews Neurology 1 and the 2012 guidelines for the management of aneurysmal subarachnoid hemorrhage published in Stroke 1.
Diagnosis and Management of Migraine
The diagnosis and management of migraine should be guided by the most recent evidence, including the 2021 study published in Nature Reviews Neurology 1, which provides a step-by-step approach to diagnosis and management.
Consideration of Other Headache Disorders
Other headache disorders, such as tension-type headaches and cluster headaches, should also be considered in the differential diagnosis, and treatment should be tailored to the specific headache type, severity, and underlying cause, as recommended in the 2002 study published in Annals of Internal Medicine 1.
From the Research
Assessment and Diagnosis
- A clear understanding of the types and possible causes of headache pain is essential to adequately assess and manage the patient with headaches 2
- Headaches can be categorized as either primary or secondary to an underlying and usually treatable cause, with most headaches being primary 2
- A thorough history and physical examination, along with a comprehensive differential diagnosis, may alert a physician to the diagnosis of a secondary headache 3, 4
Diagnostic Workup
- Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated 3
- Careful attention to the patient's history and physical examination will guide the diagnostic work-up and management 3
- Imaging plays an important role in differentiating between primary and secondary headache disorders, with computed tomography (CT) and magnetic resonance imaging (MRI) being effective tools 5
Treatment and Management
- Several general principles underlie the acute treatment of headache, including early initiation of therapy and adequate dosing at first dose 6
- Preventive treatment is indicated for frequent headaches, with successful treatment entailing low-dose medication with careful titration and monitoring of headache frequency 6
- Behavioral strategies are important and should be part of any comprehensive headache management plan 6
- Opioids should always be avoided in the treatment of headaches 6
Red Flags and Secondary Causes
- Certain clinical features, such as sudden/severe onset, focal neurologic deficits, altered mental status, and others, may suggest life-threatening secondary etiologies 3, 4
- When secondary causes are suspected, appropriate neuroimaging can further differentiate the underlying cause 3
- A comprehensive differential diagnosis should consider various primary and secondary headache etiologies 3, 4