What is the appropriate emergency department management for an adult patient presenting with a headache?

Emergency Department Headache Management

For adult patients presenting to the ED with headache, first rule out life-threatening secondary causes using red flag criteria, then treat primary headaches (predominantly migraine) with NSAIDs or combination therapy as first-line, escalating to triptans combined with NSAIDs for moderate-to-severe cases, while avoiding opioids entirely. 1

Initial Assessment: Rule Out Secondary Headaches

Red Flag Evaluation (PEACE Criteria)

Before treating as primary headache, assess for dangerous secondary causes 2:

• Neurologic examination abnormalities - Any unexplained findings warrant neuroimaging 1
• Sudden onset reaching maximum intensity within 1 hour - Suspect subarachnoid hemorrhage (SAH) 3
• Headache worsened by Valsalva maneuver 1
• Awakens patient from sleep 1
• New onset in older adults 1
• Progressively worsening pattern 1

Neuroimaging Strategy for Suspected SAH

• CT within 6 hours of headache onset has 98.7% sensitivity and can rule out SAH without further testing if interpreted by a neuroradiologist 3
• CT beyond 6 hours has significantly lower sensitivity (≤90%) and requires lumbar puncture if negative 3
• Lumbar puncture with spectrophotometry following negative CT has 100% sensitivity and 95% specificity for SAH 3

Treatment of Primary Headaches in the ED

Mild to Moderate Migraine

First-line therapy: NSAIDs 1

• Ibuprofen 400-800 mg 1
• Naproxen sodium 275-550 mg (max initial dose 825 mg) 1
• Ketorolac 60 mg IM for severe cases (rapid onset, 6-hour duration, minimal rebound risk) 1
• Aspirin 650-1,000 mg 1
• Combination: Aspirin + Acetaminophen + Caffeine (acetaminophen alone is NOT effective for migraine) 1

Administer medications as early as possible during the attack to improve efficacy 1

Moderate to Severe Migraine

Combination therapy is superior to monotherapy 1:

• Triptan + NSAID as the preferred approach 1
• Triptan + Acetaminophen when NSAIDs are contraindicated 1

Available triptans (all have good evidence): sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, eletriptan, frovatriptan 1

Newer CGRP antagonists (gepants) - rimegepant, ubrogepant, zavegepant - are options for patients who fail triptan + NSAID combination 1

Migraine with Nausea/Vomiting

Use non-oral routes of administration 1:

• Non-oral triptans (subcutaneous sumatriptan, nasal sprays) 1
• Antiemetics are essential - treat nausea as a disabling symptom, not just for vomiting 1
• Metoclopramide - improves gastric motility and provides synergistic analgesia 1
• Prochlorperazine - can effectively relieve headache pain itself 1

Tension-Type Headache

• Ibuprofen 400 mg 1
• Acetaminophen 1,000 mg 1

Status Migrainosus (Severe, Refractory Migraine)

Stepwise approach 4, 5:

1. IV fluids (only if dehydration is present) 5
2. Anti-dopaminergic agents with diphenhydramine 4
3. Corticosteroids 4
4. Divalproex IV 4
5. IV dihydroergotamine (DHE) 4
6. Nerve blocks 4

Critical Pitfalls to Avoid

Do NOT Use Opioids

Opioids (meperidine, butorphanol) should be avoided 1:

• Poor effectiveness in acute migraine 5
• Risk of dependency and rebound headaches 1
• Loss of efficacy with chronic use 1
• Do not use butalbital-containing analgesics - limit and carefully monitor 1

Medication Overuse Headache

Monitor frequency of acute medication use 1:

• NSAIDs: ≥15 days per month triggers medication overuse headache 1
• Triptans: ≥10 days per month triggers medication overuse headache 1
• Overuse of ergotamine, analgesics, and triptans causes rebound headaches 1

When to Consider Preventive Therapy

Refer for preventive therapy if 1:

• ≥2 attacks per month producing disability lasting ≥3 days 1
• Contraindication to or failure of acute treatments 1
• Use of abortive medication >2 times per week 1
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 1

Disposition and Follow-Up

Referral to a Headache Center is essential - lack of referral results in high rates of ED relapse and repeat visits 5

Patient education should include 1:

• Lifestyle modifications: hydration, regular meals, consistent sleep, aerobic exercise, stress management 1
• Identification of modifiable triggers 1
• Realistic expectations about treatment benefits and harms 1
• Medication overuse headache risk 1