Approach to Patients

Approach to Patients
Migraine Headache
Primary Headache Syndromes
Secondary Causes
Cranial and Facial Pain Disorders

Table of Contents

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To appropriately select Pt for emergency Ix and Rx of suspected critical secondary headache causes

To Dx and effectively treat Pt with generally benign and reversible secondary headache causes

To provide effective Rx for primary headache syndrome

To provide appropriate dissposition and F/U for all discharged Pt



Headache Pattern : Atypical

First severe headache

Worst headache ever

Began days earlier and steadily worson

Long-standing Hx and significantly different from prior ones in terms of duration, severity, associated symptoms.


Sudden-onset and on exertion --> Independent predictor of Intracranial Pathology --> 25 % = SAH


Non-specific and not reliable for Dx

Migrains unilateral

TTH bilateral

Occipito-nuchal location --> Independent predictor of intracranial pathology (PPV = 16 %) = Most common location for acute SAH

Associated Symptoms

Atypical features : syncope, alteration of consciousness, confusion, neck pain or stiffness, persistent visual disturbance, fever, seizure

Visual change and eye pain --> glaucoma, iritis

Jaw claudication --> temporal arteritis

Congestion and facial pain --> sinusitis

Other History

Medication : NTG, chronic NSAIDs, MAOI, anticoagulant

Trauma, Toxic exposure (CO)

Prior headache Hx

Results of previous neuroimaging

Comorbid conditions : malignancy, HIV, coagulopation, HTN

Family History

Migraine : migraines or motion sickness

SAH : Relatives with SAH, Risk of ruptured IC aneurysm in first and second degree relatives is up to 4 times


Physical Examination

Vital Sign

  • Fever : infection, SAH
  • HTN : hypertensive urgency or emergency

Head and Neck

  • Sinus
  • Temporal arteries
  • Dentition and TMJ tenderness

Eye examination

  • Glaucoma or iritis
  • Papilledema, absence of venous pulsation
  • Subhyaloid hemorrhage (gravity-dependent venous hemorrhage between the retina and vitreous hemorrhage, convex at ther bottom and flat at the top)

Neurologic Examination : Mandatory

  • MSE, CN, motor, sensory
  • Papilledema, visual field defects, meningeal signs
  • Abnormalities require emergent Ix (PPV for intracranial pathology = 39%)


Ten Headaches to Worry About

Single acute headache, characterized as first or worst of the patients life

Single acute or subacute headache with fever unexplained by other systemic illness

Single acute or subacute headache with vomiting unexplained by other systemic illness

Any headache associated with focal findings, unless focality known to be chronic and unchanged from baseline

Any headache associated with abnormal mental status, unless cognitive changes are known to be chronic and unchanged from baseline

Any headache associated with loss of spontaneous venous pulsations or papilledema

Single acute headache with pain on neck flexion, but absent on rotation

Subacute headache, unremitting or progressively worsening

Acute or subacute headache in the elderly

Any headache in the immunocompromised host, esp if HIV-positive or with risk factor for HIV


Special Consideration

Women vs Migraine

Hormonal factors

Menarche, menstruation, OCP, pregnancy, menopause

Higher estrogen levels ? improved symptoms



Improves migraine symptomes 60-70%

Older Age

Begin over 50 YO ? worrisome and herald the presence of a secondary cause
(one study found that primary headache syndromes still found the commonest Dx)


Most Pts related to underlying febrile illness or trauma

Dental causes


  • Possible but not frequent
  • Rarely does the first headache result in ED
  • FHx of Migraine and Motion Sickness

Meningitis, encephalitis, mass, IICP

HTN : If absence of fever --> prompt assessment of BP

Poisonings : CO

Major presentation in shunt malfunction

Chronic : muscle tension, vision disturbance, psychogenic causes

Analgesics and antipyretics is sufficient if thorough examination does not reveal a life-threatening condition


Using Clinical Data

According to the ACEP groupings

Headache Category

Guide to

I. Critical secondary causes requiring emergent identification and treatment
  • lEmergent Ix and have Rx initiated
II. Critical secondary causes not necessarily requiring identification and treatment
  • lIx and have Rx initiated as OPD Pt
III. Generally benign and reversible secondary causes
  • lOPD or Refer
IV. Primary headache syndromes
  • lProvide effective Rx
  • lRefer if poorly controlled


Investigation of The ED Headache Pt

Computed Tomography Scanning

ED Pt who requires emergent Ix usu begins with non-contrast CT

Noncontrast CT

  • usually adequately excludes critical lesions or mass effects requiring emergent intervention interventions
  • Best for Dx acute SAH (but cannot rule out)

Contrast CT

  • More time, expense, risk of ADR (10% + 0.1%)
  • Needed if strong suspicion of small lesions likely to be missed without contrast
    AIDS suspected of cerebral toxoplasmosis or small brain mass

Lumbar Puncture

Required in cases

  • Suspected meningitis
  • Suspected SAH with normal CT scan

Contraindications : IICP

  • papilledema, AOC, abn neuro exam
  • Venous pulsation
    • Effectively rule out IICP if present
    • May terminated temporally with pressure on the globe

Magnetic Resonance Imaging

More sensitive in brain injuries

DAI, small parenchymal contusion, isodense SDH, most tumors

No more sensitive in acute SAH in first few days

CT + LP are adequate of large majority of ED headache Pt requiring emergent Ix


Summarized By Thirayost Nimmanon

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