Acute headache management in emergency department. A narrative review

DOI: https://doi.org/10.1007/s11739-019-02266-2

Abstract-Summary Headache is a significant reason for access to Emergency Departments (ED) worldwide.

Primary forms represent the vast majority, the life-threatening potential of sec- ondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture.

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Most frequent primary forms motivating ED observation are acute migraine

attacks, particularly status migrainous, and cluster headache.

Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED.

Introduction Headache is the fourth most common reason for emergency department (ED) con- sultations, accounting for 2–3% of all visits per year in the United States (over 5 million visits in 2011] [344–347] and up to 5% in other nations [348, 349].

Secondary headaches, sustained by serious underlying pathology comprise 1 in 25 headaches among patients presenting to the emergency department [350] with forms associated with infection of the Central Nervous System (CNS) (meningitis/ encephalitis) representing 0.5%, and intracranial bleed (e.g., subarachnoid hemor- rage) and cerebrovascular accident (e.g. stroke) accounting for 1.4% of all ED head- aches [346, 351].

Once secondary forms have been ruled out, a correct diagnosis of the type of primary headache, based on the criteria of the International Classification of Headache Disorders [254] needs to be performed.

Among primary headaches, migraine and its complications, such as status migrainous, represent the main conditions motivating access to an ED, account- ing for approximately 1.2 million emergency department (ED) visits annu- ally [352].

Diagnostic Approach to the Patient with Headache in ED These include a new headache (i.e., a recent onset headache or a change in headache pattern), a late onset in life (typically over 50 years of age; a 75-year-old patient has a tenfold greater risk—11%—of serious pathology compared with a a patient aged <50 years) [353], an effort-induced headache or positional headache, thunderclap headache (see section on Secondary headache diagnoses below) post-traumatic headache, the presence of meningismus or fever, positivity for focal neurological signs, as they suggest neurologic diseases such as an intracranial mass or an arterial dissection, and the presence of significant comorbidities such as cancer or other systemic illnesses (e.g., diabetes, hypertension).

Their analysis on a cohort of 1282 neurologically intact CT-negative ED head- ache patients did not identify any cases of aneurysmal SAH showing, in contrast, that LP was associated with serious complications, a significant false-positive rate, and extended ED length of stay.

Secondary Headache Diagnoses in the ED SAH is the first and most important cause to rule out/in, although only 10% of patients presenting to the ED because of a thunderclap headache then result to have a SAH.

Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneu- rysm is relatively rare (only 1% of all headaches presenting to the ED, but 11–25% of all thunderclap headaches), however since it is one of the most deadly, with a

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median case- fatality of 27–44%, it is imperative for it to be ruled out with appropri- ate diagnostic tools in cases of suggestive symptoms [351, 354, 355].

Meningitis should always be suspected when both fever and acute headache are present in a patient [356, 357], although the number of ED patients complaining of symptoms suggestive of meningitis far exceeds that of patients who actually have the disease.

Primary Headache Diagnoses in the ED Migraine has a prevalence of 12% in the general population, but the degree of dis- ability related to the disorder makes it a prominent primary diagnosis in headache disorders.

Steiner et al. reported, within the same GBD 2016, that it is the first cause of dis- ability in patients under 50 years of age, especially considering the association with three potential health state that contributes to the burden of migraine: the ictal state (during an attack), the interictal state (between recurrent attacks) and medication overuse [358].

Migraine is indeed the most common primary headache condition motivating presentation to the ED [359], often patients have a status migrainosus, one of its complications, with or without aura, consisting of an attack lasting more than 72 h. Cluster headache also often motivates access to the ED, this is an easy diagnosis considering the typical clinical signs, unilaterality, strong autonomic accompanying signs (nasal congestion and discharge, flushing, tearing), duration of the attacks not outlasting 150 min, and the typical periodical presentation for the attacks.

Treatment Approach to the Headache Patient in the ED NSAIDs are a typical choice for treating acute headache attacks in an Emergency Setting, among which ketorolac, whose effectiveness, either intramuscularly (IM) or intravenously (IV) is supported by good evidence [360–363].

They have a clear relative inefficacy in relieving pain of an acute migraine attack (patients who receive intravenous hydromorphone in the ED are much less likely to attain acute headache relief) [364] and present an association with increased rates of return to presentation to an Emergency Setting [365, 366].

Their relative scarce effectiveness, combined with the possible adverse events (urinary retention, nausea, edema, constipation, pruritus, up to seizures and respira- tory depression) and the risk of inducing, over time, tolerance, dependence and addiction in chronic pain patients, should strongly discourage their use for acute headache treatment in the emergency setting [367].

Corticosteroids (e.g., dexamethasone IV) are frequently used to treat acute head- aches in the ED [368], particularly in the case of status migranosus or intense head- ache in patients with medication overuse, although controlled studies in support of its efficacy are lacking [369].

Conclusions Headache sufferers represent a significant proportion of patients presenting to an ED. Primary forms most frequently motivating ED observation are acute migraine attacks, particularly status migrainous, cluster headache or headache in patients with medication-overuse.

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According to Gupta et al. [370] only 22% of patients were pain free on discharge from a university ED, with 64% of patients discharged with improvement having a return of severe headache within 24 h. Among the causes of the relatively lack of treatment success is the lack of correct referral of the patient to an adequate struc- ture/physician for the prosecution of the therapy, especially prophylaxis.

In synthesis, optimal management of a patient with headache in an ED necessar- ily passes through correct diagnosis at the beginning, but also to adequate referral of the patient to a specialist after treatment of the acute phase has been performed.

Acknowledgement A machine generated summary based on the work of Giamberardino, Maria Adele; Affaitati, Giannapia; Costantini, Raffaele; Guglielmetti, Martina; Martelletti, Paolo. 2020 in Internal and Emergency Medicine.

Emergency Neurological Life Support: Subarachnoid Hemorrhage