Emergency Department and Inpatient Management of Headache in Adults

DOI: https://doi.org/10.1007/s11910-020-01030-w

Abstract-Summary This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM).

Most patients presenting with headache in the ED will have migraine, but red

flags must be reviewed to rule out secondary headaches.

SM refractory to home treatment is a common reason for ED presentation or

inpatient admission, but high-quality treatment evidence is lacking.

This article details red flags to review in the workup of headache presentation in

the ED and provides a step-wise approach to ED and inpatient management.

Extended: This article reviews the currently available evidence to provide a step- wise approach, but more studies are needed to better guide management in these settings.

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4 Treatment

Introduction Neurologic disorders account for at least one-tenth of presentations to the emer- gency department (ED) with approximately one- fourth of these presentations being headache related [336–338].

Patients presenting to the ED with primary headaches frequently get workups

despite the majority having migraine without red flags.

Status migrainosus (SM) is a common reason for presentation to the ED and may

represent nearly one-fifth of headache- related ED presentations [337, 338].

In clinical practice, SM-like presentations are frequently seen as severe migraine attacks lasting greater than 72 h overlying a baseline chronic daily headache; this makes true diagnosis of status migrainosus less clear despite patients having symp- toms that are often managed as SM.

Most patients with SM have a low rate of frequency of attacks, and their fre- quency of SM attacks does not appear to increase after an episode of SM resolves [339].

Identifying Secondary Headaches Nye and Ward [340] provided an excellent overview of red flags to consider in the ED that includes the SNOOP4 criteria, age <5 years, and headache worsening under observation.

All patients with headache need funduscopic examination performed specifically

for consideration of papilledema.

The decision of when and how to investigate headache is based on concern for a specific secondary headache, which guides appropriate investigation into potential differential diagnoses.

If there is concern for a secondary headache, magnetic resonance imaging should always be chosen over computed tomography when available, except for situations that require immediate imaging such as thunderclap headache or stroke.

Aura and Mimics Sample, they devised a stroke mimic scoring system with 100% specificity if the score is more than 5, but a sensitivity of only 15% [341]:Age:<50 years = 2 points 50–70 years = 1 point > 70 years = 0 pointsStroke risk factors: hypertension, hyper- lipidemia, diabetes, atrial fibrillation (AF) No risk factors = 3 points1 risk factor other than AF = 2 points≥2 risk factors other than AF = 1 pointAF = 0 pointsOther factors:Migraine = 2 pointsEpilepsy = 1 pointPsychiatric illness = 1 point Lebedeva et al. [342] also looked at differentiating aura from a transient ischemic attack and proposed diagnostic criteria for transient ischemic attack with a sensitivity of 99% and a specificity of 95–96%:A.Sudden onset of fully reversible neurologic or retinal symptoms (e.g. hemiparesis, hemi-numbness, aphasia, neglect, amaurosis fugax, hemianopia, hemiataxia) B.Duration < 24 hC. At least 2 of the following:a.

No headache within 1 h of symptomsD.None of the following isolated symp- toms: shaking spells, diplopia, dizziness, syncope, decreased level of conscious- ness, confusion, hyperventilation-associated paresthesia, unexplained falls, amnesiaE.No acute infarct in relevant territory on imaging Ultimately, clinic judg- ment is still required until tools like these are validated, but using the type of reason- ing these tools provide may help guide diagnosis.

4.4 Emergency Department Management

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Management SM and severe headache attacks not responding to acute treatment at home are a common reason for presentation to the ED, with patients often requiring admission. This section outlines the current evidence and provides guidance on one approach to managing severe migraine attacks including SM in the ED and inpatient setting. A systematic review from 2015 that included 25 studies on the use of corticoste- roids for migraine showed that steroids improve headache and the response to non- steroidal treatment [343].

If IVF, anti-dopaminergic agents, NSAIDs, dexamethasone, and DHE provide insufficient relief, the next step is to repeat doses of medications already tried such as prochlorperazine or DHE to perform nerve blocks or to consider other treatments with less evidence.

Intravenous anti-epileptics are often included in treatment, most commonly IV

divalproex.

The AHS gave magnesium sulfate 1–2 g IV level B evidence for acute treatment

of migraine with aura.

Conclusions The vast majority will be migraine, but red flags must be carefully reviewed to rule out secondary headaches requiring targeted investigations and treatment.

SM or severe migraine attacks refractory to home treatment are common reasons

for presentation with headache to the ED or for inpatient admission.

Patients who are refractory to outpatient treatments often receive recurrent inpa- tient treatment with little evidence- based guidance as far as combined pharmaco- logic and behavioral management.

Emergency and inpatient management of headache is an important area with

much room for improvement.

Acknowledgement A machine generated summary based on the work of Robblee, Jennifer; Grimsrud, Kate W. 2020 in Current Neurology and Neuroscience Reports.

Acute headache management in emergency department. A narrative review