What is the emergent evaluation and management for a patient presenting with headache, vomiting, and abdominal pain?

Emergent Evaluation and Management of Headache, Vomiting, and Abdominal Pain

This triad of symptoms demands immediate exclusion of life-threatening secondary causes—particularly subarachnoid hemorrhage, meningitis, and intra-abdominal catastrophes—before considering primary headache disorders. 1

---

Immediate Red-Flag Assessment

Critical Features Requiring Urgent Neuroimaging (Non-Contrast CT Head)

• Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds to minutes) suggests subarachnoid hemorrhage and requires immediate non-contrast head CT. 2, 1
• Neck stiffness or fever with headache and vomiting suggests meningitis; obtain urgent neuroimaging before lumbar puncture if focal deficits or altered consciousness are present. 1
• Focal neurological deficits (weakness, sensory loss, visual field cuts, ataxia) suggest space-occupying lesion, intracerebral hemorrhage, or stroke. 1
• Altered consciousness or confusion indicates increased intracranial pressure or infectious/metabolic encephalopathy. 1
• Headache worsening with Valsalva, coughing, or sneezing suggests mass effect or increased intracranial pressure. 1
• Postural headache (worse upright, better lying flat) suggests spontaneous intracranial hypotension, though this typically does not present with abdominal pain. 1

Abdominal Pain Evaluation in the Context of Headache

• Acute abdominal pain with peritoneal signs (guarding, rebound tenderness, rigidity) requires surgical evaluation for intra-abdominal infection, perforation, or ischemia. 2
• Right lower quadrant pain with fever suggests appendicitis; the presence of vomiting before pain onset makes appendicitis less likely. 2
• Hypotension, tachycardia, or signs of hypoperfusion (oliguria, lactic acidosis, altered mental status) indicate sepsis or hemorrhagic shock requiring immediate resuscitation. 2
• Physical examination should assess for peritonitis (pain, tenderness, guarding) and systemic inflammatory response (fever, tachycardia, tachypnea). 2

---

Diagnostic Approach: Step-Up Algorithm

Step 1: Clinical and Laboratory Examination

• Complete blood count, metabolic panel, lactate to assess for infection, metabolic derangement, or organ dysfunction. 2
• Lipase/amylase if epigastric pain suggests pancreatitis. 2
• Urinalysis and pregnancy test (in women of childbearing age) to exclude urinary tract infection, pyelonephritis, or ectopic pregnancy. 2
• Blood cultures if fever or sepsis is suspected. 2

Step 2: Imaging Based on Clinical Suspicion

For Headache with Red Flags

• Non-contrast head CT is the gold standard for acute hemorrhage and should be performed immediately if subarachnoid hemorrhage is suspected. 1
• Lumbar puncture if CT is negative but subarachnoid hemorrhage remains suspected (xanthochromia, elevated red blood cells). 2, 1
• MRI brain is more sensitive for posterior fossa lesions, venous sinus thrombosis, and meningitis but may be limited by availability in the emergency setting. 1

For Abdominal Pain

• Ultrasound as initial imaging for right lower quadrant pain (appendicitis), right upper quadrant pain (cholecystitis), or pelvic pain in women. 2
• CT abdomen/pelvis with IV contrast if ultrasound is inconclusive or if complicated intra-abdominal infection, perforation, or bowel obstruction is suspected. 2
• Diagnostic laparoscopy may be required if imaging is unhelpful and clinical suspicion for surgical pathology remains high (accuracy 86–100%). 2

---

Management of Secondary Causes

If Subarachnoid Hemorrhage is Confirmed

• Immediate neurosurgical consultation for aneurysm management. 2
• Blood pressure control with short-acting IV agents (e.g., nicardipine, labetalol) to prevent rebleeding while avoiding excessive hypotension. 2
• Avoid antihypertensives that may mask neurological deterioration; target systolic BP <160 mm Hg until aneurysm is secured. 2

If Meningitis is Suspected

• Empiric antibiotics (ceftriaxone 2 g IV + vancomycin 15–20 mg/kg IV) should be administered immediately after blood cultures are drawn, without waiting for lumbar puncture if there is any delay in imaging. 1
• Dexamethasone 10 mg IV before or with the first antibiotic dose reduces mortality and neurological sequelae in bacterial meningitis. 1

If Intra-Abdominal Infection is Confirmed

• Source control (surgical drainage, resection, or percutaneous drainage) is the cornerstone of treatment for complicated intra-abdominal infections. 2
• Broad-spectrum antibiotics (e.g., piperacillin-tazobactam 4.5 g IV q6h or meropenem 1 g IV q8h) should be initiated immediately after cultures are obtained. 2
• Fluid resuscitation and vasopressors if septic shock is present. 2

---

Management of Primary Headache (After Secondary Causes Excluded)

If Migraine with Vomiting is Diagnosed

First-line IV therapy in the emergency department:

• Metoclopramide 10 mg IV provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties. 3, 1
• Ketorolac 30 mg IV (or 60 mg IM if age <65 years) has rapid onset, approximately 6 hours duration, and minimal rebound headache risk. 3, 1
• This combination (metoclopramide + ketorolac) is the recommended first-line parenteral regimen for severe migraine with vomiting. 3, 1

Alternative parenteral options if first-line fails:

• Prochlorperazine 10 mg IV is comparable in efficacy to metoclopramide but has a higher rate of akathisia (21% vs. 50% for chlorpromazine). 3
• Dihydroergotamine (DHE) 0.5–1.0 mg IV has good evidence for efficacy as monotherapy; contraindicated with concurrent triptan use (within 24 hours), beta-blockers, uncontrolled hypertension, coronary artery disease, pregnancy, or sepsis. 3, 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes; useful when IV access is unavailable or vomiting prevents oral administration. 3, 1

Critical contraindications to triptans:

• Ischemic heart disease, previous myocardial infarction, coronary artery vasospasm, uncontrolled hypertension, cerebrovascular disease, stroke/TIA, basilar or hemiplegic migraine. 3

---

Medication-Overuse Headache Prevention

• Limit all acute migraine medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 3, 1
• If acute treatment is required >2 days per week, initiate preventive therapy immediately (e.g., propranolol 80–240 mg/day, topiramate, amitriptyline 30–150 mg/day). 3, 4

---

Disposition and Follow-Up

• Admit patients with confirmed secondary causes (subarachnoid hemorrhage, meningitis, complicated intra-abdominal infection) for definitive treatment. 2, 1
• Discharge patients with primary headache after symptom resolution, with strict return precautions for red-flag features (thunderclap headache, focal deficits, fever, altered consciousness). 1
• Refer to headache specialist if headaches are frequent (≥2 attacks per month with ≥3 days of disability) or if acute medications are used >2 days per week. 3, 4
• Provide headache diary to track frequency, severity, triggers, and medication use. 3

---

Common Pitfalls to Avoid

• Do not attribute headache and vomiting to migraine without first excluding subarachnoid hemorrhage, meningitis, and increased intracranial pressure. 1, 5
• Do not delay antibiotics for lumbar puncture if bacterial meningitis is suspected and imaging is not immediately available. 1
• Do not prescribe opioids (hydromorphone, meperidine) for migraine; they have limited efficacy, high risk of medication-overuse headache, and potential for dependence. 3, 4
• Do not allow patients to increase acute medication frequency in response to treatment failure; transition to preventive therapy instead. 3, 4
• Do not miss abdominal migraine or cyclical vomiting syndrome in patients with recurrent episodes of vomiting and abdominal pain without headache, especially in children and adolescents. 6