ED - Acute headache and migraine (≥ 18 Years)
Last Updated: 7/8/2016 1:53:32 PM
Order Set
  Associated Pathway(s)
 Acute headache and migraine (> 18 Years) - http://www.curbsideup.com/link/2195
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  Inclusion Criteria
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
  Avoid opioids 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.

  General
  General
Nursing communication
Q1 hour pain score
  Migraine Headache AND tolerating PO (even if nauseous)

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
  Contraindications to triptans or use within the past 24 hrs?
      Contraindications to triptans: Ischemic cardiovascular disease, Uncontrolled arterial hypertension, Prior stroke, Prinzmetal's angina, Hemiplegic migraine, Pregnancy, Use within the last 24 hours
No
Rizatriptan tab
10 mg, PO, Once
  Contraindications to promethazine?
      Contraindications to promethazine: Pediatric age patients (concern for respiratory depression), Patients with respiratory depression or distress (including asthma)
No
Promethazine PO
25 mg, PO, Once
  Contraindications to NSAIDs?
      Contraindications to NSAIDS: Stomach ulcer, Coagulopathy, Active bleeding, Renal insufficiency
No
Ibuprofen PO
600 mg, PO, Once
  Migraine Headache AND NOT tolerating PO
  Contraindications to triptans or use within the past 24 hrs?
      Contraindications to triptans: Ischemic cardiovascular disease, Uncontrolled arterial hypertension, Prior stroke, Prinzmetal's angina, Hemiplegic migraine, Pregnancy, Use within the last 24 hours
No
Sumatriptan SQ
6 mg, SQ, Once
  IV fluids
NS bolus IV
1000 mL, IV, Once
  Contraindications to metaclopramide?
      Contraindications to metoclopramide: Mechanical GI obstruction, perforation, or hemorrhage, Pheochromocytoma
No
Metoclopramide IV
10mg, IV, Once, give over 2 mintues
  Contraindications to NSAIDs?
      Contraindications to NSAIDS: Stomach ulcer, Coagulopathy, Active bleeding, Renal insufficiency
No
Ketorolac IV
30 mg, IV, Once
  Tension Headache

If patient with tension type headache fails NSAIDs in the ED, consider treating the patient along the migraine pathway if appropriate.

  Contraindications to NSAIDs?
      Contraindications to NSAIDS: Stomach ulcer, Coagulopathy, Active bleeding, Renal insufficiency
No
Ibuprofen PO
600 mg, PO, Once
  Cluster Headache

Symptoms consistent with cluster headaches

  • Male > Female (4.3:1)
  • Side-locked unilateral SEVERE pain typically around the eye or temporal region
  • Each episodes lasts 15-180 min and recurs 1-8 times per day
  • Restless
  • Ipsilateral autonomic symptoms (lacrimation, conjunctival injection, eyelid ptosis, eyelid swelling, aural fullness, congestion/rhinorrhea, pallor/sweating
  • Sensitivity to alcohol
  Features of a cluster headache present?
      Provide oxygen therapy only if there are no contraindications to oxygen by past medical history
Yes
Oxygen
Oxygen 15 L/min by non-rebreather for 15 minutes
  Contraindications to triptans or use within the past 24 hrs?
      Contraindications to triptans: Ischemic cardiovascular disease, Uncontrolled arterial hypertension, Prior stroke, Prinzmetal's angina, Hemiplegic migraine, Pregnancy, Use within the last 24 hours
No
Sumatriptan SQ
6 mg, SQ, Once
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