Improved enough for discharge?
Consult neurology
Symptoms of secondary headache
- Altered mental status, papilledema, focal neurologic findings, seizure
- Fever, URI symptoms, pharyngitis, sinusitis, encephalitis/meningitis symptoms
- Allergic symptoms, rash
- Weight loss
- Thunderclap (sudden) onset
- Headache precipitated by valsalva
- Headache symptoms positional
Dihydroergotamine 0.3mg IV over 1 minute, if needed may repeat in 15 minutes with 1mg IV over 10-15 min (should have pretreated with metoclopramide 10mg IV over 2 minutes unless contraindicated)
Meets discharge criteria?
Discharge
Consider neurology consult
Improved enough for discharge?
Triptans in the last 24 hours?
Inital IV treatment (give all unless contraindicated)
- Non-traumatic headache
- Systemic symptoms of disease: (fever, meningismus, etc.)
- Focal neurologic symptoms
- Sudden or abrupt onset of headache (e.g. thunderclap)
- First severe headache or pattern change from prior headaches
- Precipitation by Valsalva, postural component of headache or papilledema
- High risk factors for secondary headache: (immunosuppression, malignancy, etc.)
- Pregnancy
Inappropriate drug seeking behavior?
Check local prescription drug monitoring programs, off pathway
Cluster headache features?
Tolerating PO (even if nauseous)?
Improved enough for discharge?
Contraindications to triptans or use within 24 hrs
Improved enough for discharge?
Continued significant headache?
Inital PO treatment (give all unless contraindicated)
Migraine features present?
Improved enough for discharge?
Naproxen 550 mg PO PRN (no more than 10 days per month), follow-up with PCP
Improved enough for discharge?
Symptoms consistent with cluster headaches
- Male > Female (4.3:1)
- Side-locked unilateral SEVERE pain typically around the eye or temporal region
- Episodes lasts 15-180 min and recurs 1-8 times/day
- Restless
- Ipsilateral autonomic symptoms (lacrimation, conjunctival injection, eyelid ptosis, eyelid swelling, aural fullness, congestion/rhinorrhea, pallor/sweating
- Sensitivity to alcohol
Improved enough for discharge?
Lidocaine 4% nasal spray, 1 spray per nostril
- Occipital nerve block
- Bupivicaine 0.75% 10mL available in a 10mL syringe, 2mL injected into bilateral occipital grooves in a sterile fashion. If pregnant, use lidocaine.
Contraindications to metoclopramide
- Mechanical GI obstruction, perforation, or hemorrhage
- Pheochromocytoma
- Contraindications to promethazine
- Pediatric age patients (concern for respiratory depression)
- Patients with respiratory depression or distress (including asthma)
- If the patient develops akathisia consider the use of IV/IM diphenhydramine
Contraindications to Valproic Acid
- LFT abnormalities
- History of liver disease
- Pregnancy
Contraindications to steroids (specific to headache)
- Currently taking steroids for other reason
- Received steroids for headache within the past 2-4 weeks
Contraindications to Dihydroergotamine
- History of stroke or CAD
- Uncontrolled hypertension
- Pregnancy
- Use of triptans within previous 24h
- Promethazine 25 mg PO Q6h PRN
- Naproxen 550 mg PO PRN (no more than 10 days per month)
- Follow-up with PCP
Ibuprofen, reevaluate in 1 hour
If triptans were helpful
- Rizatriptan 10 mg TbDL (or Imitrex 100 mg if prefered). One tab PO at the onset of headache. May repeat once after 2 hrs if needed. May not exceed 2 doses in 24 hours or 10 days per month. Dispense 10 tabs.
- Promethazine 25 mg PO Q6h PRN
If NSAIDs were helpful
- Naproxen 550 mg PO PRN (no more than 10 days per month)
If headache > 72 hours and no contraindications to steroids then consider steroids to prevent recurrence
- Dexamethasone 6 PO x1 in the ED
- Dexamethasone 5 mg PO BID x 2 days, 4 mg BID x 2 days, 3 mg BID x 2 days, 1 mg BID x 2 days. Do not take too late in the day.
Famotidine 20 mg PO BID for 8 days
Follow-up with PCP (and/or Neurologist if appropriate)
Patients should be informed that they should not drive or operate machinery if they have recieved medications that may cause drowsiness
Symptoms consistent with migraine
- Headache lasting more than 4 hours
- Pulsating quality
- Nausea and/or vomiting
- Photophobia and/or phonophobia
- Moderate/severe pain intensity
- Aggravated by routine physical activity
- Cluster Headache
- Oxygen 15 L/min by non-rebreather for 15 minutes (if not contrainidicated by pmhx)
Symptoms consistent with tension headache
- Bilateral/diffuse location
- Pressure/tightness that waxes and wanes
- Patient may remain active despite headache
- Mild/moderate pain intensity
- Non-throbbing quality
- May be associated with nausea, photophobia and phonophobia, but rarely vomiting
Avoid opiods in all headache patients
- Almost all patients with headache, even those with severe pain and underlying medical conditions, can be managed with non-opioid regimens. Every effort to avoid opioids in these patients should be made as they offer no benefit and can lead to poor long term outcomes.
Suggested criteria for discharge
- Reduction of headache pain by 50% or more
- Reassuring vital signs
- Tolerating PO
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Patient comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
Contraindications to triptans
- Ischemic cardiovascular disease
- Uncontrolled arterial hypertension
- Prior stroke
- Prinzmetal's angina
- Hemiplegic migraine
- Pregnancy
- Previous use twice or more within the last 24 hours
- Previous use more than 10 days in the prior month
Contraindications to NSAIDS
- Stomach ulcer
- Coagulopathy
- Active bleeding
- Renal insufficiency
- Pregnancy
Contraindications to magnesium
- Pregnancy
- Patients with neuromuscular disease (e.g. myasthenia gravis)
- Patient with renal impairment
If NSAIDs were helpful
- Naproxen 550mg PO PRN (no more than 10 days per month)
If magnesium was helpful
- Magnesium (chelated form) 400-600mg PO QD
- Consider discharge with triptan as well
If DHE helpful
- Send home with triptans: Rizatriptan 10 mg TbDL (or Imitrex 100 mg if prefered). One tab PO at the onset of headache. May repeat once after 2 hrs if needed. May not exceed 2 doses in 24 hours or 10 days per month. Dispense 10 tabs.
If Valproic Acid helpful
- Valproic Acid PO: 250 mg TID x3 days then 250 mg BID x3 days then 250 mg QDay x3 days then stop
- Neurology follow up and for them to manage valproic acid usage outpatient
If headache > 72 hours and no contraindications to steroids then consider steroids to prevent recurrence
- Dexamethasone 6 PO x1 in the ED
- Dexamethasone 5 mg PO BID x 2 days, 4 mg BID x 2 days, 3 mg BID x 2 days, 1 mg BID x 2 days. Do not take too late in the day.
Famotidine 20 mg PO BID for 8 days
Promethazine 25 mg PO Q6hrs PRN
Follow-up with PCP (and/or Neurologist if appropriate)
Patients should be informed that they should not drive or operate machinery if they have recieved medications that may cause drowsiness
Sumatriptan 6 mg SQ (repeat in 1 hour if not headache free, may use zolmitriptan nasal spray if preferred)
Consider neurology consult and/or neuroimaging
