Acute headache and migraine (> 18 Years) - Curbside
Acute headache and migraine (> 18 Years)
Editors: Dan Imler, MD, Addie Peretz
Inclusion Criteria  (Any one criteria present)
  • Non-traumatic headache
Exclusion Criteria
  • 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

Consider neurology consult and/or neuroimaging

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Evidence
Total Notes: 17
Evidence

1 Cluster headache

Cluster headaches are an uncommon presentation of headache affecting less than 1 percent of the population. They likely originate from excessive hypothalamic activation with secondary activation of the trigeminal-autonomic reflex.

Clinically, cluster headaches typically manifest as severe orbital/supraorbital or temporal pain with assoicated agitation that short-lived, but occur frequently (including multiple times in the same day). Importantly, cluster headaches are always unilateral with the associated symptoms on the same side of the head during an attack (although the symptoms may move to the other side with subsequent attacks). Attacks are often associated with autonomic symptoms (miosis, ptosis, conjunctival injection, nasal congestion/rhinorrhea) that occur on the same side as the pain.

Diagnostic criteria

  • At least five attacks
  • Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
  • Either or both of the following
    • At least one of the following symptoms or signs, ipsilateral to the headache
      • Conjunctival injection and/or lacrimation
      • Nasal congestion and/or rhinorrhoea
      • Eyelid edema
      • Forehead and facial sweating
      • Forehead and facial flushing
      • Sensation of fullness in the ear
      • Miosis and/or ptosis
    • A sense of restlessness or agitation
  • Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active
  • Not better accounted for by another ICHD-3 diagnosis.


References:
  1. Cluster headache.
    Nesbitt AD, Goadsby PJ,
    BMJ 2012;344:e2407.
  2. The International Classification of Headache Disorders, 3rd edition (beta version).

    Cephalalgia 2013 Jul;33(9):629-808.
  3. Cluster headache: a prospective clinical study with diagnostic implications.
    Bahra A, May A, Goadsby PJ,
    Neurology 2002 Feb;58(3):354-61.
  4. Cluster headache prevalence. Vg study of headache epidemiology.
    Sjaastad O, Bakketeig LS,
    Cephalalgia 2003 Sep;23(7):528-33.
  5. The incidence and prevalence of cluster headache: a meta-analysis of population-based studies.
    Fischera M, Marziniak M, Gralow I, Evers S,
    Cephalalgia 2008 Jun;28(6):614-8.
  6. Age at onset and sex ratio in cluster headache: observations over three decades.
    Ekbom K, Svensson DA, Trff H, Waldenlind E,
    Cephalalgia 2002 Mar;22(2):94-100.
  7. Gender ratio of cluster headache over the years: a possible role of changes in lifestyle.
    Manzoni GC,
    Cephalalgia 1998 Apr;18(3):138-42.
  8. Cluster headache in the Taiwanese -- a clinic-based study.
    Lin KH, Wang PJ, Fuh JL, Lu SR, Chung CT, Tsou HK, Wang SJ,
    Cephalalgia 2004 Aug;24(8):631-8.
  9. Cluster headache--clinical findings in 180 patients.
    Manzoni GC, Terzano MG, Bono G, Micieli G, Martucci N, Nappi G,
    Cephalalgia 1983 Mar;3(1):21-30.
  10. Cluster headache: pathogenesis, diagnosis, and management.
    May A,
    Lancet;366(9488):843-55.
  11. Dysfunction of the sympathetic nervous system in cluster headache.
    Drummond PD,
    Cephalalgia 1988 Sep;8(3):181-6.
  12. Sweating and vascular responses in the face: normal regulation and dysfunction in migraine, cluster headache and harlequin syndrome.
    Drummond PD,
    Clin. Auton. Res. 1994 Oct;4(5):273-85.
  13. Mechanisms of autonomic disturbance in the face during and between attacks of cluster headache.
    Drummond PD,
    Cephalalgia 2006 Jun;26(6):633-41.
  14. Evaluation of clinical criteria for cluster headache with special reference to the classification of the International Headache Society.
    Ekbom K,
    Cephalalgia 1990 Aug;10(4):195-7.

2 Oxygen therapy for cluster headache

100% O2 has been shown to improve the symptoms of cluster headache in several small studies although some patients did not receive relief. Oxygen should be administered to optimize FiO2. A non-rebreathing face mask at 15L/min in an upright position for a minimum of 15 minutes (even if symptoms initially resolve) is suggested. Patients with contraindications to 100% O2 (e.g. COPD) should obviously not receive O2.



References:
  1. Oxygen treatment of cluster headache: a review.
    Petersen AS, Barloese MC, Jensen RH,
    Cephalalgia 2014 Nov;34(13):1079-87.
  2. Acute and preventive pharmacologic treatment of cluster headache.
    Francis GJ, Becker WJ, Pringsheim TM,
    Neurology 2010 Aug;75(5):463-73.
  3. High-flow oxygen for treatment of cluster headache: a randomized trial.
    Cohen AS, Burns B, Goadsby PJ,
    JAMA 2009 Dec;302(22):2451-7.
  4. Response of cluster headache attacks to oxygen inhalation.
    Kudrow L,
    Headache 1981 Jan;21(1):1-4.
  5. Treatment of cluster headache. A double-blind comparison of oxygen v air inhalation.
    Fogan L,
    Arch. Neurol. 1985 Apr;42(4):362-3.
  6. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache.
    Bennett MH, French C, Schnabel A, Wasiak J, Kranke P,
    Cochrane Database Syst Rev 2008(3):CD005219.
  7. Treatment of cluster headache: clinical trials, design and results.
    Ekbom K,
    Cephalalgia 1995 Oct;15 Suppl 15:33-6.
  8. Cluster headache: pathogenesis, diagnosis, and management.
    May A,
    Lancet;366(9488):843-55.
  9. High oxygen flow rates for cluster headache.
    Rozen TD,
    Neurology 2004 Aug;63(3):593.

3 Secondary headache

Headache may be a secondary symptom to other disease processes, some of which may be life threatening. Identification of patients presenting with secondary headache is key to early intervention with this population.

In an adult primary care headache study 39 percent of patient's symptoms were from a systemic disorder (i.e. fever, hypertension, etc.) and 5 percent were due to a neurologic disorder. Sinusitis is commonly misdiagnosed as the cause of headache with up to 90% of patients actually having migraine.

In children, headache is rarely associated with a serious secondary disorder. In the ED secondary headache is commonly associated with viral syndrome. In the primary care setting 1.1% of patients were diagnosed with a secondary headache and 79.7% with no diagnosis.



References:
  1. Serious neurological disorders in children with chronic headache.
    Abu-Arafeh I, Macleod S,
    Arch. Dis. Child. 2005 Sep;90(9):937-40.
  2. Headaches in a pediatric emergency department: etiology, imaging, and treatment.
    Kan L, Nagelberg J, Maytal J,
    Headache 2000 Jan;40(1):25-9.
  3. Headache etiology in a pediatric emergency department.
    Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M,
    Pediatr Emerg Care 1997 Feb;13(1):1-4.
  4. Sinus headache or migraine? Considerations in making a differential diagnosis.
    Cady RK, Schreiber CP,
    Neurology 2002 May;58(9 Suppl 6):S10-4.
  5. Headache in children in Dutch general practice.
    van der Wouden JC, van der Pas P, Bruijnzeels MA, Brienen JA, van Suijlekom-Smit LW,
    Cephalalgia 1999 Apr;19(3):147-50.
  6. What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records.
    Kernick D, Stapley S, Campbell J, Hamilton W,
    Cephalalgia 2009 Dec;29(12):1311-6.
  7. Etiology and distribution of headaches in two Brazilian primary care units.
    Bigal ME, Bordini CA, Speciali JG,
    Headache 2000 Mar;40(3):241-7.

4 Tension headaches

Tension headaches are a mild to moderate intensity headache that may last from 30 min to a few days. They are usually non-throbbing in character, but other symptoms (photophobia or phonophobia) may overlap with migraine. As opposed to migraine tension headaches, they are rarely accompanied with nausea/vomiting or worsen with physical activity. Although the cause of tension headache is not clearly known it is thought they are secondary to exaggerated pain response in susceptible individuals.

Treatment of intermittent, infrequent tension headaches is primarily supportive-emotional and NSAIDs. Validation of stressors, bio-feedback and non-medical interventions may be useful in the management of acute and frequent episodes. Patients with frequent or chronic tension headache may require further medications which should be discussed with a neurologist.

Of note, chronic use of NSAIDs may result in medication overuse headache and should be discussed with the patient.



References:
  1. The history, epidemiology, and classification of headaches in childhood.
    Scheller JM,
    Semin Pediatr Neurol 1995 Jun;2(2):102-8.
  2. An epidemiologic study of headache among children and adolescents of southern Brazil.
    Barea LM, Tannhauser M, Rotta NT,
    Cephalalgia 1996 Dec;16(8):545-9; discussion 523.
  3. The International Classification of Headache Disorders, 3rd edition (beta version).

    Cephalalgia 2013 Jul;33(9):629-808.
  4. Migrainous disorder and headache of the tension-type not fulfilling the criteria: a follow-up study in children and adolescents.
    Zebenholzer K, Wber C, Kienbacher C, Wber-Bingl C,
    Cephalalgia 2000 Sep;20(7):611-6.
  5. Bilateral, wide-spread, mechanical pain sensitivity in children with frequent episodic tension-type headache suggesting impairment in central nociceptive processing.
    Fernndez-de-Las-Peas C, Fernndez-Mayoralas DM, Ortega-Santiago R, Ambite-Quesada S, Gil-Crujera A, Fernndez-Jan A,
    Cephalalgia 2010 Sep;30(9):1049-55.
  6. Generalized mechanical nerve pain hypersensitivity in children with episodic tension-type headache.
    Fernndez-Mayoralas DM, Fernndez-de-las-Peas C, Ortega-Santiago R, Ambite-Quesada S, Jimnez-Garca R, Fernndez-Jan A,
    Pediatrics 2010 Jul;126(1):e187-94.
  7. Applicability of the 1988 IHS criteria to headache patients under the age of 18 years attending 21 Italian headache clinics. Juvenile Headache Collaborative Study Group.
    Gallai V, Sarchielli P, Carboni F, Benedetti P, Mastropaolo C, Puca F,
    Headache 1995 Mar;35(3):146-53.
  8. Pain experience of children with headache and their families: A controlled study.
    Aromaa M, Sillanp M, Rautava P, Helenius H,
    Pediatrics 2000 Aug;106(2 Pt 1):270-5.
  9. Myth: Ibuprofen is superior to acetaminophen for the treatment of benign headaches in children and adults.
    Manzano S, Doyon-Trottier E, Bailey B,
    CJEM 2010 May;12(3):220-2.
  10. Solubilized ibuprofen: evaluation of onset, relief, and safety of a novel formulation in the treatment of episodic tension-type headache.
    Packman B, Packman E, Doyle G, Cooper S, Ashraf E, Koronkiewicz K, Jayawardena S,
    Headache;40(7):561-7.
  11. Risk of development of medication overuse headache with nonsteroidal anti-inflammatory drug therapy for migraine: a critically appraised topic.
    Starling AJ, Hoffman-Snyder C, Halker RB, Wellik KE, Vargas BB, Dodick DW, Demaerschalk BM, Wingerchuk DM,
    Neurologist 2011 Sep;17(5):297-9.
  12. Patterns of medication use by chronic and episodic headache sufferers in the general population: results from the frequent headache epidemiology study.
    Scher AI, Lipton RB, Stewart WF, Bigal M,
    Cephalalgia 2010 Mar;30(3):321-8.

5 Contraindications to triptans

Although several studies have shown that triptans are generally safe, the limited evidence has created the enviroment where most bodys do not recommend triptans for patients with: pregnancy, ischemic heart disease, Prinzmetal's angina, stroke, uncontrolled hypertension, hemiplegic migraine or basilar migraine.

Typically triptans are not recommended to be used more than twice in 24 hours and separated by 2 hours with each use. Triptans are also recommended to be avoided if the patient has used them more than 10 days in the prior month as taking more than 10 days of triptans per month causes rebound headaches.



References:
  1. Triptans for acute cluster headache.
    Law S, Derry S, Moore RA,
    Cochrane Database Syst Rev 2010(4):CD008042.
  2. Cluster headache attacks treated for up to three months with subcutaneous sumatriptan (6 mg). Sumatriptan Cluster Headache Long-term Study Group.
    Ekbom K, Krabbe A, Micieli G, Prusinski A, Cole JA, Pilgrim AJ, Noronha D, Micelli G [corrected to Micieli G],
    Cephalalgia 1995 Jun;15(3):230-6.
  3. Cardiovascular tolerability and safety of triptans: a review of clinical data.
    Dodick DW, Martin VT, Smith T, Silberstein S,
    Headache 2004 May;44 Suppl 1:S20-30.
  4. Adverse cardiovascular events associated with triptans and ergotamines for treatment of migraine: systematic review of observational studies.
    Roberto G, Raschi E, Piccinni C, Conti V, Vignatelli L, D'Alessandro R, De Ponti F, Poluzzi E,
    Cephalalgia 2015 Feb;35(2):118-31.
  5. Triptans in migraine: the risks of stroke, cardiovascular disease, and death in practice.
    Hall GC, Brown MM, Mo J, MacRae KD,
    Neurology 2004 Feb;62(4):563-8.
  6. The safety of triptans in the treatment of patients with migraine.
    Jamieson DG,
    Am. J. Med. 2002 Feb;112(2):135-40.
  7. The association of the combination of sumatriptan and methysergide in myocardial infarction in a premenopausal woman.
    Liston H, Bennett L, Usher B, Nappi J,
    Arch. Intern. Med. 1999 Mar;159(5):511-3.
  8. Concomitant triptan and SSRI or SNRI use: what is the risk for serotonin syndrome?
    Evans RW,
    Headache 2008 Apr;48(4):639-40.
  9. Serotonin syndrome risks when combining SSRI/SNRI drugs and triptans: is the FDA's alert warranted?
    Wenzel RG, Tepper S, Korab WE, Freitag F,
    Ann Pharmacother 2008 Nov;42(11):1692-6.
  10. Drug interactions with triptans : which are clinically significant?
    Rolan PE,
    CNS Drugs 2012 Nov;26(11):949-57.

6 Triptans for cluster headache

Multiple large RCTs have shown that triptans are safe and effective in the treatment of cluster headache. It is considered the first line therapy at this time.



References:
  1. Triptans for acute cluster headache.
    Law S, Derry S, Moore RA,
    Cochrane Database Syst Rev 2010(4):CD008042.
  2. Treatment of acute cluster headache with sumatriptan. The Sumatriptan Cluster Headache Study Group.

    N. Engl. J. Med. 1991 Aug;325(5):322-6.
  3. Subcutaneous sumatriptan in the acute treatment of cluster headache: a dose comparison study. The Sumatriptan Cluster Headache Study Group.
    Ekbom K, Monstad I, Prusinski A, Cole JA, Pilgrim AJ, Noronha D,
    Acta Neurol. Scand. 1993 Jul;88(1):63-9.
  4. Cluster headache attacks treated for up to three months with subcutaneous sumatriptan (6 mg). Sumatriptan Cluster Headache Long-term Study Group.
    Ekbom K, Krabbe A, Micieli G, Prusinski A, Cole JA, Pilgrim AJ, Noronha D, Micelli G [corrected to Micieli G],
    Cephalalgia 1995 Jun;15(3):230-6.
  5. Intranasal sumatriptan in cluster headache: randomized placebo-controlled double-blind study.
    van Vliet JA, Bahra A, Martin V, Ramadan N, Aurora SK, Mathew NT, Ferrari MD, Goadsby PJ,
    Neurology 2003 Feb;60(4):630-3.
  6. Effectiveness of intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind crossover study.
    Cittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ,
    Arch. Neurol. 2006 Nov;63(11):1537-42.
  7. Zolmitriptan nasal spray in the acute treatment of cluster headache: a double-blind study.
    Rapoport AM, Mathew NT, Silberstein SD, Dodick D, Tepper SJ, Sheftell FD, Bigal ME,
    Neurology 2007 Aug;69(9):821-6.
  8. Oral zolmitriptan is effective in the acute treatment of cluster headache.
    Bahra A, Gawel MJ, Hardebo JE, Millson D, Breen SA, Goadsby PJ,
    Neurology 2000 May;54(9):1832-9.
  9. Medication-overuse headache in patients with cluster headache.
    Paemeleire K, Bahra A, Evers S, Matharu MS, Goadsby PJ,
    Neurology 2006 Jul;67(1):109-13.

7 Alternative cluster headache treatments

Several alternative treatments (Octreotide, intranasal lidocaine, Ergots) have been used in cluster headaches. They are, however, inferior in efficacy to triptans.



References:
  1. Subcutaneous octreotide in cluster headache: randomized placebo-controlled double-blind crossover study.
    Matharu MS, Levy MJ, Meeran K, Goadsby PJ,
    Ann. Neurol. 2004 Oct;56(4):488-94.
  2. Treatment of acute cluster headache with sumatriptan. The Sumatriptan Cluster Headache Study Group.

    N. Engl. J. Med. 1991 Aug;325(5):322-6.
  3. Intranasal sumatriptan in cluster headache: randomized placebo-controlled double-blind study.
    van Vliet JA, Bahra A, Martin V, Ramadan N, Aurora SK, Mathew NT, Ferrari MD, Goadsby PJ,
    Neurology 2003 Feb;60(4):630-3.
  4. Intranasal lidocaine for cluster headache.
    Robbins L,
    Headache 1995 Feb;35(2):83-4.
  5. Best BETs from the Manchester Royal Infirmary. BET 2: should intranasal lidocaine be used in patients with acute cluster headache?
    Morgan A, Jessop V,
    Emerg Med J 2013 Sep;30(9):769-70.
  6. The effect of intranasal cocaine and lidocaine on nitroglycerin-induced attacks in cluster headache.
    Costa A, Pucci E, Antonaci F, Sances G, Granella F, Broich G, Nappi G,
    Cephalalgia 2000 Mar;20(2):85-91.
  7. Nerves and vessels in the pterygopalatine fossa and symptoms of cluster headache.
    Hardebo JE, Elner A,
    Headache 1987 Nov;27(10):528-32.
  8. Cluster headache. Local anesthetic abortive agents.
    Kittrelle JP, Grouse DS, Seybold ME,
    Arch. Neurol. 1985 May;42(5):496-8.
  9. Cluster headache: pathogenesis, diagnosis, and management.
    May A,
    Lancet;366(9488):843-55.
  10. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias.
    May A, Leone M, Afra J, Linde M, Sndor PS, Evers S, Goadsby PJ, Goadsby PJ,
    Eur. J. Neurol. 2006 Oct;13(10):1066-77.
  11. Dihydroergotamine nasal spray in the treatment of attacks of cluster headache. A double-blind trial versus placebo.
    Andersson PG, Jespersen LT,
    Cephalalgia 1986 Mar;6(1):51-4.
  12. The treatment of cluster headache with repetitive intravenous dihydroergotamine.
    Mather PJ, Silberstein SD, Schulman EA, Hopkins MM,
    Headache 1991 Sep;31(8):525-32.
  13. Intravenous dihydroergotamine for inpatient management of refractory primary headaches.
    Nagy AJ, Gandhi S, Bhola R, Goadsby PJ,
    Neurology 2011 Nov;77(20):1827-32.

8 Migraine headache



References:
  1. Triptan therapy in migraine.
    Loder E,
    N. Engl. J. Med. 2010 Jul;363(1):63-70.
  2. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium.
    Kelley NE, Tepper DE,
    Headache 2012 Jan;52(1):114-28.
  3. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings.
    Orr SL, Aub M, Becker WJ, Davenport WJ, Dilli E, Dodick D, Giammarco R, Gladstone J, Leroux E, Pim H, Dickinson G, Christie SN,
    Cephalalgia 2015 Mar;35(3):271-84.

9 Magnesium

Magnesium sulfate IV can be an effective acute migraine treatment especially for patients with a history of migraine with aura. Side effects include flushing and burning of the head and neck. 



References:
  1. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study.
    Bigal ME, Bordini CA, Tepper SJ, Speciali JG,
    Cephalalgia 2002 Jun;22(5):345-53.
  2. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium.
    Kelley NE, Tepper DE,
    Headache 2012 Jan;52(1):114-28.

10 Blank



References:
  1. Intravenous valproate sodium (depacon) aborts migraine rapidly: a preliminary report.
    Mathew NT, Kailasam J, Meadors L, Chernyschev O, Gentry P,
    Headache 2000 Oct;40(9):720-3.

11 Valproic Acid for migraine

No RCTs have been conducted evaluating the efficacy of valproic acid in the acute treatment of acute migraine, however, there have been a number of open label trials demonstrating efficacy for valproic acid. The American Headache Society 2016 evidence assessment of parenteral pharmacotherapeutics for the treatment of acute migraine in the Emergency Department states that valproic acid may be given for the acute treatment of migriane based on Level C evidence. 



References:
  1. Intravenous sodium valproate aborts migraine headaches rapidly.
    Shahien R, Saleh SA, Bowirrat A,
    Acta Neurol. Scand. 2011 Apr;123(4):257-65.
  2. Treatment of primary headache disorders with intravenous valproate: initial outpatient experience.
    Stillman MJ, Zajac D, Rybicki LA,
    Headache 2004 Jan;44(1):65-9.


12 Blank

RCTs have evaluated parenteral, oral, suppository, nasal formulations of various triptans for short-term treatment of migraine. 13 RCTs have shown a mean therapeutic gain of 51 percentage points for sumatriptan SQ versus placebo.  Onset of action is approximately 10 minutes for sumatriptan SQ. Oral sumatriptan 100mg dose has a mean therapeutic gain of 29 percentage points in 53 randomized double-blind controlled trials. 

Triptans have been associated with rebound or medication overuse headaches, especially when used more than 10 days per month. Minor very common adverse events include paresthesias, flushing, mild transient tightness or chest pressure. Most patients with triptan-induced neck or chest pain do not have EKG changes or other evidence of decreased myocardial perfusion. Contraindications include poorly controlled hypertension, severe hepatic or renal impairment, basilar or hemiplegic migraine, known vasospastic or ischemic CAD, pregnancy.



References:

13 Opioids treatment in headache

Opioids are commonly used as the treatment for migraine, HOWEVER, opioids are generally not effective and are associated with tolerance, dependence, addiction, and overdose. Therefore, all efforts should be used to avoid opioids for the treatment of headache.



References:
  1. Excessive acute migraine medication use and migraine progression.
    Bigal ME, Lipton RB,
    Neurology 2008 Nov;71(22):1821-8.
  2. Opioids should not be used in migraine.
    Tepper SJ,
    Headache 2012 May;52 Suppl 1:30-4.
  3. Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications.
    Kelley NE, Tepper DE,
    Headache 2012 Mar;52(3):467-82.
  4. Evaluating the use and timing of opioids for the treatment of migraine headaches in the emergency department.
    Tornabene SV, Deutsch R, Davis DP, Chan TC, Vilke GM,
    J Emerg Med 2009 May;36(4):333-7.




  5. The American Academy of Neurology's top five choosing wisely recommendations.
    Langer-Gould AM, Anderson WE, Armstrong MJ, Cohen AB, Eccher MA, Iverson DJ, Potrebic SB, Becker A, Larson R, Gedan A, Getchius TS, Gronseth GS,
    Neurology 2013 Sep;81(11):1004-11.
  6. EFNS guideline on the drug treatment of migraine--revised report of an EFNS task force.
    Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sndor PS, Sndor PS,
    Eur. J. Neurol. 2009 Sep;16(9):968-81.

14 Tension headaches

Tension headaches are a mild to moderate intensity headache that may last from 30 min to a few days. They are usually non-throbbing in character, but other symptoms (photophobia or phonophobia) may overlap with migraine. As opposed to migraine tension headaches, they are rarely accompanied with nausea/vomiting or worsen with physical activity. Although the cause of tension headache is not clearly known it is thought they are secondary to exaggerated pain response in susceptible individuals.

Treatment of intermittent, infrequent tension headaches is primarily supportive-emotional and NSAIDs. Validation of stressors, bio-feedback and non-medical interventions may be useful in the management of acute and frequent episodes. Patients with frequent or chronic tension headache may require further medications which should be discussed with a neurologist.

Of note, chronic use of NSAIDs may result in medication overuse headache and should be discussed with the patient.



References:
  1. The International Classification of Headache Disorders, 3rd edition (beta version).

    Cephalalgia 2013 Jul;33(9):629-808.
  2. The Global Burden of Disease survey 2010, Lifting The Burden and thinking outside-the-box on headache disorders.
    Martelletti P, Birbeck GL, Katsarava Z, Jensen RH, Stovner LJ, Steiner TJ,
    J Headache Pain 2013;14:13.
  3. Central sensitization in tension-type headache--possible pathophysiological mechanisms.
    Bendtsen L,
    Cephalalgia 2000 Jun;20(5):486-508.
  4. Peripheral and central mechanisms in tension-type headache: an update.
    Jensen R,
    Cephalalgia 2003;23 Suppl 1:49-52.
  5. The global burden of headache: a documentation of headache prevalence and disability worldwide.
    Stovner Lj, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA,
    Cephalalgia 2007 Mar;27(3):193-210.
  6. Epidemiology of headache in a general population--a prevalence study.
    Rasmussen BK, Jensen R, Schroll M, Olesen J,
    J Clin Epidemiol 1991;44(11):1147-57.
  7. Epidemiology of headache.
    Rasmussen BK,
    Cephalalgia 1995 Feb;15(1):45-68.
  8. A comparison of tension-type headache in migraineurs and in non-migraineurs: a population-based study.
    Ulrich V, Russell MB, Jensen R, Olesen J,
    Pain 1996 Oct;67(2-3):501-6.
  9. Interrelations between migraine and tension-type headache in the general population.
    Rasmussen BK, Jensen R, Schroll M, Olesen J,
    Arch. Neurol. 1992 Sep;49(9):914-8.
  10. Rates and predictors for relapse in medication overuse headache: a 1-year prospective study.
    Katsarava Z, Limmroth V, Finke M, Diener HC, Fritsche G,
    Neurology 2003 May;60(10):1682-3.
  11. Medication overuse headache: rates and predictors for relapse in a 4-year prospective study.
    Katsarava Z, Muessig M, Dzagnidze A, Fritsche G, Diener HC, Limmroth V,
    Cephalalgia 2005 Jan;25(1):12-5.
  12. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force.
    Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J, Schoenen J,
    Eur. J. Neurol. 2010 Nov;17(11):1318-25.
  13. Pharmacotherapy of tension-type headache (TTH).
    Lenaerts ME,
    Expert Opin Pharmacother 2009 Jun;10(8):1261-71.
  14. [Treatment of tension type headache: paracetamol and NSAIDs work: a systematic review].
    Verhagen AP, Damen L, Berger MY, Lenssinck ML, Passchier J, Kroes BW,
    Ned Tijdschr Geneeskd 2010;154:A1924.

15 Headache

Headache is one of the most common chief complaints of patients seaking care representing up to 4-5% of all Emergency department visits. Key to the care of headache patients is the identification of the cause/type of headache the patient is presenting with and identification of high risk signs for secondary headache and serious underlying disease.

A common mnemonic SNOOP has been used to identify signs of secondary headache

  • Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised state including HIV)
  • Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures)
  • Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap")
  • Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity)
  • Previous headache history with headache progression or change in attack frequency, severity, or clinical features


References:
  1. Etiology and distribution of headaches in two Brazilian primary care units.
    Bigal ME, Bordini CA, Speciali JG,
    Headache 2000 Mar;40(3):241-7.
  2. Emergency management of headache.
    Edmeads J,
    Headache 1988 Nov;28(10):675-9.
  3. Classification of primary headaches.
    Lipton RB, Bigal ME, Steiner TJ, Silberstein SD, Olesen J,
    Neurology 2004 Aug;63(3):427-35.
  4. Headaches that kill: a retrospective study of incidence, etiology and clinical features in cases of sudden death.
    Lynch KM, Brett F,
    Cephalalgia 2012 Oct;32(13):972-8.
  5. Headache as a symptom of ominous disease. What are the warning signals?
    Dodick D,
    Postgrad Med 1997 May;101(5):46-50, 55-6, 62-4.
  6. Case 13: a man with progressive headache and confusion.
    Venkatesan A,
    MedGenMed 2006;8(3):19.
  7. Intermittent headaches as the presenting sign of subacute angle-closure glaucoma.
    Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR,
    Neurology 2005 Sep;65(5):757-8.
  8. Migraine diagnosis and treatment: results from the American Migraine Study II.
    Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF,
    Headache;41(7):638-45.
  9. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache.
    Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL,
    Arch. Neurol. 1997 Dec;54(12):1506-9.
  10. Management of primary headaches in adult Emergency Departments: a literature review, the Parma ED experience and a therapy flow chart proposal.
    Torelli P, Campana V, Cervellin G, Manzoni GC,
    Neurol. Sci. 2010 Oct;31(5):545-53.

16 Blank

There are no RCTs evaluating valproic acid for the treatment of acute migraine although there have been a number of open label prospective studies showing efficacy of valproic acid in the acute treatment of migraine. According to the American Headache Society 2016 evidence assessment of parenteral pharmacotherapeutics for the treatment of acute migriane in the ED, valproic acid may be offered to adults for acute migraine treatment based on Level C evidence. 



References:


17 Dopamine receptor antagonists

Multiple studies have evaluated the efficacy of dopamine receptor antagonists in the acute treatment of migraine demonstrating efficacy when compared with other conventional treatments such as NSAIDs, triptans, opiates and also superior to placebo. The American Headache Society 2016 evidence assessment of parenteral pharmacotherapeutics for the treatment of acute migraine in the Emergency Department states that metoclopramide and prochlorperazine should be offered for the acute treatment of migraine.  



References: