Rosen & Barkin's 5-Minute Emergency Medicine Consult (319 page)

Read Rosen & Barkin's 5-Minute Emergency Medicine Consult Online

Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
11.67Mb size Format: txt, pdf, ePub
Second Line
  • Narcotics
  • Corticosteroids
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Persistent headache unresponsive to usual measures
  • Unclear headache diagnosis
Discharge Criteria
  • Patients with moderate to complete pain relief, a normal neurologic exam, and with a confident diagnosis of cluster headache
  • Consider prescribing oxygen and/or SC sumatriptan for management at home
Issues for Referral

Follow-up with a neurologist should be arranged

PEARLS AND PITFALLS
  • History is essential to diagnose cluster headache as pain may be improved upon presentation
  • 100% oxygen should be the 1st treatment initiated
  • Cluster headaches may be so severe that they lead to suicide
    • Follow-up is essential to manage clusters which may last months
ADDITIONAL READING
  • Cohen AS,Burns B, GoadsbyPJ. High-flow oxygen for treatment of cluster headache: A randomizedtrial.
    JAMA.
    2009;302:2451–2457.
  • Friedman BW, Grosberg BM. Diagnosis and management of the primary headache disorders in the emergency department setting.
    Emerg Med Clin North Am
    . 2009;27:71–87.
  • McGeeney BE. Cluster Headache Pharmacotherapy.
    Am J Ther
    . 2005;12:351–358.
  • Nesbitt AD, Goadsby PJ. Cluster headache.
    BJM
    . 2012;344:e2407.
See Also (Topic, Algorithm, Electronic Media Element)
  • Headache
  • Headache, migraine
CODES
ICD9
  • 339.00 Cluster headache syndrome, unspecified
  • 339.01 Episodic cluster headache
  • 339.02 Chronic cluster headache
ICD10
  • G44.009 Cluster headache syndrome, unspecified, not intractable
  • G44.019 Episodic cluster headache, not intractable
  • G44.029 Chronic cluster headache, not intractable
HEADACHE, MIGRAINE
Benjamin W. Friedman
BASICS
DESCRIPTION
  • Chronic episodic headache disorder
  • Neurovascular pathophysiology:
    • Aberrant trigeminal nerve activation
    • Activation of nociceptive pathways within brainstem
    • Vascular dilation reactive rather than causative
    • No longer considered primarily a vascular headache
    • Disordered sensory processing and autonomic dysfunction
    • Cortical spreading depression underlies aura
  • 1 million ED visits per year
  • Causes majority of ED headache visits
  • 3× as common in women
  • Prevalence peaks in 4th decade of life
  • Established criteria for migraine without aura:
    • A. 5 attacks fulfilling criteria B, C, D, E
    • B. Attack lasts 4–72 hr
    • C. Headache has 2 of the following:
      • 1. Unilateral location
      • 2. Pulsating
      • 3. Moderate to severe pain (impairs activities)
      • 4. Aggravation by or avoidance of physical activity
    • D. During headache, nausea, or vomiting and/or photophobia + phonophobia
    • E. Not attributable to other cause
  • Migraine with aura:
    • Less common
    • Classically, reversible neurologic symptoms that precede headache
    • Some patients report aura at the same time or after the headache
    • Rarer subtypes of migraine include:
      • Basilar type migraine
        • Dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness
      • Hemiplegic migraine
        • Full reversible motor weakness
      • Retinal migraine
        • Repeated attacks of monocular visual disturbance
Pediatric Considerations
  • More commonly bilateral pain and shorter duration of headache
  • Associated symptoms may be difficult to elicit and can be inferred from behavior
  • Cyclical vomiting syndrome associated with migraine
  • High placebo response
ETIOLOGY

Genetic disorder with variable penetrance, influenced by the environmental factors

DIAGNOSIS
SIGNS AND SYMPTOMS
History
  • May be precipitated by chocolate, cheese, nuts, alcohol, sulfites, monosodium glutamate (MSG), stress, or menstruation
  • Prodrome precedes migraine by several days
    • May consist of cognitive or emotional alterations, yawning, drowsiness
  • Aura precedes migraine by 1 hr
    • Most commonly consists of visual or sensory disturbances
      • Scintillating scotoma
      • Fortification spectra
      • Numbness or tingling
  • Headache typically unilateral, throbbing
  • Sufficiently intense to impair activity
  • Can be bilateral
  • Usually associated with osmophobia, photophobia, phonophobia, nausea, or vomiting
  • Usually gradual onset
  • History often reflects similar headache previously
Physical-Exam
  • Allodynia (sensitivity to normally non-noxious stimuli) may be present and signifies more refractory migraine
  • Physical exam should otherwise be normal
  • Physical exam should include exam of fundi and assessment of visual fields
  • Elevated blood pressure does not exclude migraine as diagnosis
  • Sinus tenderness does not exclude migraine as diagnosis
ESSENTIAL WORKUP
  • An accurate history and physical exam confirm the diagnosis
  • Patients with new headache syndrome may require workup including imaging and spinal fluid analysis
DIAGNOSIS TESTS & NTERPRETATION
Lab

Clinical diagnosis: None required

Imaging

Clinical diagnosis: None required

Diagnostic Procedures/Surgery

Clinical diagnosis: None required

DIFFERENTIAL DIAGNOSIS
  • Cluster headache
  • Medication overuse headache
  • Tension-type headache
  • Allergic or viral rhinosinusitis
  • Idiopathic intracranial hypertension (pseudotumor cerebri)
  • Reversible cerebral vasoconstriction syndrome
TREATMENT
PRE HOSPITAL
  • Allow patients with migraine headache to be in a calm, dark environment
  • Oxygen may be beneficial
INITIAL STABILIZATION/THERAPY
  • Exclude secondary causes of headache
  • Rapid and effective analgesia
ED TREATMENT/PROCEDURES
  • Detailed history will exclude secondary cause of headache in most patients
  • Provide analgesia without relying upon opioid analgesics
  • IV saline hydration is often helpful
  • Provide patient with diagnosis – “You have a migraine”, education about trigger avoidance
Pregnancy Considerations

Metoclopramide, prochlorperazine best treatment options in pregnancy

MEDICATION
  • Abortive therapy in ED:
    • Dopamine antagonists:
      • Prochlorperazine 10 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia
      • Droperidol 2.5 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia (check EKG prior)
      • Metoclopramide 10 mg IV
      • Trimethobenzamide 200 mg IM
    • Triptans:
      • Sumatriptan: 6 mg SC (avoid if cardiac risk factors)
      • Eletriptan 40 mg PO
    • Ergot alkaloids:
      • Dihydroergotamine: 1 mg IV, coadministered with an antiemetic (avoid if cardiac risk factors; avoid if on macrolide or antiretrovirals)
    • Nonsteroidals
      • Ketorolac 30 g IV
    • Corticosteroids
      • Dexamethasone 10 mg IV or IM
      • Prednisone taper

Other books

Bouvard and PÈcuchet by Gustave Flaubert
The Finkler Question by Howard Jacobson
Trust Me to Know You by Jaye Peaches
Alien Revealed by Lilly Cain
The Return of Moriarty by John E. Gardner
Hijos de un rey godo by María Gudín
The Hanging Garden by Patrick White