Inpatient Headache

Lauren Waskowicz

Background 

  • Important to distinguish primary and secondary headache
  • “Red flags” for secondary headaches (SNOOPPP): Systemic symptoms, focal Neurologic symptoms, Onset that is sudden (thunderclap), Older age (new headache >40), Progression or evolution in previous headaches, Postural component, Pregnancy
  • Other red flags: preceding trauma, headache awakening pt from sleep, no headache-free intervals

Evaluation 

  • Get a good description of where the pain is, when it started, associated symptoms, and assess for “red flag” features listed above
  • If there are any red flag features, imaging and possible further workup may be necessary
  • Imaging depends on highest suspicions, but CTA head/neck is appropriate to evaluate for aneurysm, dissection or vasospasm. If any focal signs, MRI is generally preferred; venous imaging can be beneficial in headaches with features of elevated ICP
  • Would consider lumbar puncture for evaluation of opening pressure if features of elevated ICP present and venous imaging negative. Ophthalmologic evaluation for papilledema also appropriate.
  • Would order ESR/CRP and ophthalmologic evaluation in older patients with temporal headache and other symptoms concerning for GCA such as vision changes, jaw claudication
  • If no red flag features are present, then workup is not necessary, and focus is on treatment

Management 

  • NSAIDs and Tylenol for infrequent headaches, but consistent use (>2-3x/week) runs the risk of medication overuse headaches
  • Triptans for migraine, but contraindicated in patients with CAD, uncontrolled hypertension, previous stroke, hemiplegic migraine. They must be used within 6 hour of onset
    • There are theoretical concerns of serotonin syndrome when used with SSRI/SNRIs
  • Migraines:
    • “Migraine cocktail”: 1L fluid bolus, 4g Mg, IV Compazine(10mg) OR Phenergan(20mg) with Benadryl (25mg)
    • 2nd line: Depakote 1000 mg IV, Decadron 10mg IV , +/- Toradol 30mg IV, Flexeril 10mg PO
  • Cluster headache
    • Triptans, high flow O2 (>10 L), can consider intranasal Lidocaine if no arrhythmia history
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