Improved enough for discharge?
Consult neurology
Symptoms of secondary headache
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)
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
Improved enough for discharge?
Lidocaine 4% nasal spray, 1 spray per nostril
Contraindications to metoclopramide
Contraindications to Valproic Acid
Contraindications to steroids (specific to headache)
Contraindications to Dihydroergotamine
Ibuprofen, reevaluate in 1 hour
If triptans were helpful
If NSAIDs were helpful
If headache > 72 hours and no contraindications to steroids then consider steroids to prevent recurrence
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
Symptoms consistent with tension headache
Avoid opiods in all headache patients
Suggested criteria for discharge
Contraindications to triptans
Contraindications to NSAIDS
Contraindications to magnesium
If NSAIDs were helpful
If magnesium was helpful
If DHE helpful
If Valproic Acid helpful
If headache > 72 hours and no contraindications to steroids then consider steroids to prevent recurrence
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