Overview of Headache in the Emergency Department

Key Chapter Points

About 2–3% of all ED visits are for headache. Migraine is the #1 diagnosis for nontraumatic headache seen in the emergency department, accounting for 40–60% of all nontraumatic, emergency department headaches. While migraine sufferers usually obtain routine headache care with outpatient providers, ED treatment is generally sought when pain becomes unbearable, patient’s current headache regimen is not effective, or a patient’s primary headache provider is unavailable. ED visits are expensive and often very frustrating for staff and patients. Common errors of ED headache assessment include focusing on identifying a specific primary headache diagnosis rather than distinguishing primary from secondary headaches, misunderstanding the role of hypertension, failing to identify unreported trauma, and using treatment response to confirm a diagnosis.

Box 1.1 Case Presentation

Janice is a 37-year-old mother who presents to the emergency department (ED) with a chief complaint of severe headache and nausea. She has had migraines since she was in college. Her headaches are usually well managed at home with over-the-counter analgesics and a nap. Her current headache began the previous evening and failed to respond to her usual treatments. After sending her boys to school this morning, she came to the ED. Janice has been in a crowded waiting room for the last 2 h, holding a damp wash cloth over her eyes, moaning, and occasionally dry heaving into an emesis basin Box 1.1 (continued) she brought with her. “My headaches usually aren’t this bad and my doctor’s office doesn’t open until 9, so I thought I’d just stop in the emergency room and get my headache taken care of right away. If I could just lie down in a dark quiet room, I’d feel so much better, but the nurse said I have to wait until they’re less busy to take care of me. Sitting here under these fluorescent lights with people yelling and babies crying has just made everything even worse! I asked the nurse if they could just give me a strong pain killer that I could take home with me. She looked at me like I was a junkie or something! I’m sure the nurse is hoping I’ll give up and leave, but I’m afraid if I leave now, I’ll just end up having to wait even longer at my doctor’s office.”

In the ED, headache patients may be triaged to lower priority service, with more expedient care provided to patients with chest pain, severe infections, or trauma. Headache patients like Janice often become frustrated, as waiting in a busy, bright, loud ED can aggravate symptoms for many patients with severe headache. ED providers may be equally frustrated with visits from patients reporting chronic headaches, concerned that some of these patients may be malingering and drug seeking.

 

Headache is one of the most common symptoms resulting in emergency or urgent care treatment. Using national statistics data about emergency service use, headache accounted for 2.6% of all emergency visits, making headache the fourth most common reason for visiting an emergency department (ED), tied with back symptoms (Fig. 1.1) [1]. On average, six headache patients visit an ED every minute in the USA [2].

Fig. 1.1

Reasons for ED visits in the USA (based on [1] and reproduced with permission from Marcus DA and Bain PA. Effective migraine treatment in pregnant and lactating women. Humana Press 2009)

Although headache is frequently seen in the ED, headache is not an area of major focus during ED training. For example, disease area categories comprising the greatest weight on the American Board of Emergency Medicine’s initial certification examination are trauma (11%) and cardiovascular (10%), abdominal and gastrointestinal (9%), and thoracic–respiratory disorders (8%) [3]. Categories that might contain headache include head, ear, eye, nose, and throat disorders (5% of the examination) and nervous system disorders (5%). Limited formal headache training and lack of available standardized or evidence-based management protocols for managing urgent headache complaints can make ED staff uncomfortable caring for headache patients. Furthermore, analgesics that offer only modest efficacy in primary headache, such as narcotics, are often routinely used for ED headache treatment, with limited benefit. These patients may return to the ED requesting additional care for persistent or recurrent headache, leading to a cycle of inappropriate, repeated ED visits for headache management and concerns about drug-seeking behavior.

Understanding the issues commonly seen in headache patients presenting to the ED and developing assessment and treatment strategies to expedite effective care can improve treatment outcomes for ED visits for headache. Satisfaction of both providers and patients may also improve by adopting streamlining strategies based on understanding which headache disorders most commonly present to the ED, why patients choose ED care, and what errors commonly confound ED headache management.

Most Non-traumatic Headaches in the ED Are Primary Headaches

Headaches can be divided into primary and secondary headaches. Secondary headaches can be directly attributed to underlying disease, pathology, or trauma, while primary headaches are not caused by another identifiable disease or medical condition.

Pearl for the practitioner:

Primary headaches are those headaches, like migraine and tension-type headache, that are not attributed to other medical conditions. Secondary headaches are headaches directly caused by other underlying conditions or injury.

The second edition of the International Headache Classification ICHD-II diagnostic criteria lists 47 unique primary headaches [4]. The most common primary headaches are migraine and tension-type headaches (Table 1.1). Several primary headaches are short-lived and infrequently seen in the ED; typical durations of these relatively short-duration headaches are 60–90 min for cluster headaches, 2–30 min for paroxysmal hemicrania, and seconds to minutes for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA syndrome).

Table 1.1 Primary headache disorders (ICHD-II criteria)

In most cases, nontraumatic head pain seen in the ED is caused by benign, primary, recurring headaches. In a prospective, 11-month, observational survey, discharge diagnoses were analyzed for all ED patients presenting with a chief complaint of nontraumatic headache [5]. Migraine was the most common diagnosis, with only 16% of headaches assigned a secondary headache diagnosis (Fig. 1.2).

Fig. 1.2

Discharge diagnoses in consecutive ED patients with nontraumatic headache (based on [5]). TIA transient ischemic attack

Similarly, data from the National Hospital Ambulatory Medical Care Survey reported 2.1 million ED visits annually for nontraumatic headache, accounting for 2.2% of all ED visits [6]. In this survey, migraine was again the most common single diagnosis, affecting two in every three patients treated in the ED for nontraumatic headache (63.5%). The next most common diagnoses were tension-type headache (3.4%), viral syndrome (2.4%), and anxiety/psychiatric diagnosis (1.1%). Twenty percent of headaches were diagnosed as “other benign conditions,” including hypertension and infectious conditions affecting the ears, sinuses, or throat, gastroenteritis, or periapical (tooth) abscess. Pathological diagnoses (including meningitis, encephalitis, stroke, hemorrhage, aneurysm, glaucoma, benign intracranial hypertension, giant cell/temporal arteritis, or hypertensive encephalopathy) were assigned to only 2% of headaches among all patients seen for nontraumatic headache. A pathological diagnosis was most common in middle and older aged adults, accounting for 6% of nontraumatic headaches in patients ≥50 years old and 11% in those ≥75 years old. The evaluation for possible secondary headaches is detailed in Chap.  3.

Pearl for the practitioner:

Migraine is the single most common cause of nontraumatic headache in patients seen in the ED:

• Up to 60% of patients seen in the ED for nontraumatic headache will have migraine.

• Rare but important secondary headaches are more common in middle and older aged adults, especially in patients over age 75. These will be covered in detail in Chap.  3.

Why Do Headache Patients Come to the ED?

The ED is generally not the ideal environment for managing headaches. Most patients seeking ED treatment for nontraumatic head pain have primary headaches, especially migraine. Migraine sufferers usually prefer dark, quiet, comforting solitude during severe headaches – the exact opposite of most EDs. Also, patients with acute headaches presenting to the ED may be viewed by ED personnel as potential drug seekers or patients seeking inappropriate ED care for nonemergent conditions. Headache experts agree that chronic headaches are best managed in outpatient facilities rather than the ED. For a variety of reasons, however, many patients, like Janice, will at least occasionally seek out ED treatment.

Although primary headaches constitute the bulk of ED visits for nontraumatic headache, most patients with severe headache are managed outside of an emergency setting. A survey of 13,451 adults with severe headache found that only 6% had visited an ED during the preceding year, with half of these using the ED on only a single occasion [7]. Frequent ED use occurred for only 1% of the sample, although this minority of patients constituted 51% of all ED headache visits. Understanding why patients repeatedly seek ED treatment and devising strategies to facilitate more appropriate outpatient management can reduce episodes of frequent, often inappropriate use of the ED for primary headache management.

Pearl for the practitioner:

Most patients with severe headache obtain care outside of the ED. Over half of all ED visits for severe, nontraumatic headache are made by a small minority of patients who repeatedly seek headache care in the ED. Strategies need to be developed to minimize inappropriate return visits for this group of patients.

ED care is also an expensive way to manage chronic headaches. A review of ED visits for migraine in 2005 reported that the average per-patient cost for an ED visit for migraine was $1,799 [8]. This total did not include additional charges for transportation to the ED (with 24% of patients having arrived at the ED via ambulance) or radiologist fees for interpreting neuroimaging studies, which had been performed in 22% of patients.

If the ED is not very conducive to headache management and is so costly, then why is headache such a common chief complaint for ED visits? To understand why headache patients come to the ED, people with severe headache participating in the American Migraine Prevalence and Prevention study were asked about ED use [7]. Among the 859 individuals surveyed who had visited an ED at least once during the previous year, unbearable pain and inability to contact an outpatient provider were the most common reasons cited for seeking headache care in the ED (Fig. 1.3). These data highlight a tremendous opportunity. Many of these patients might more appropriately seek headache management in an outpatient, primary care practice if the opportunity were available. Also, these data suggest that, by appropriately diagnosing patients, initiating effective treatment, and arranging post-ED follow-up care, future unnecessary ED visits for recurring headaches can be minimized. A well thought out headache strategy can lead to more satisfied patients and providers as well as more cost-effective care.

Fig. 1.3

Reasons for headache patients sought headache care in the ED during the previous year (based on [7]). Patients were allowed to endorse >1 reason

Pearl for the practitioner:

Migraine sufferers who present to the ED for headache usually do so because of unbearable pain and an inability to obtain care from their primary care provider or other headache-interested provider. A coordinated plan of care and ongoing relationship with a headache-interested provider can dramatically reduce ED visits for headache.

ED Headache Treatment is Often Unsatisfactory for Both Patients and ED Staff

Many patients fail to achieve a satisfactory outcome when receiving ED management for nontraumatic headaches. A survey of 219 patients seen in the ED for acute nontraumatic headache reported insufficient treatment and persistent headache for a substantial number of surveyed patients [9]. Two-thirds of the patients in this sample were diagnosed with migraine. During their ED visit, two-thirds of the patients were treated with medications, most commonly neuroleptics or opioids, while one-third received neither medications nor intravenous rehydration. Only 22% were pain-free at discharge, with moderate to severe headache remaining in 35%. Furthermore, diaries completed during the 24-h after discharge showed that headache returned for 64% of patients.

Pearl for the practitioner:

Studies have shown that one in three patients presenting to the ED with acute headache will continue to report moderate or severe headache upon ED discharge. Headache will recur in two of three patients during the first day after ED discharge.

ED staff are also often dissatisfied with headache management. Working in an ED is difficult and can be frustrating. Data collected in 2004 reported that, while 65% of emergency physicians endorsed high career satisfaction, 33% reported that burnout was a significant problem [10]. A subsequent survey of a random sample from the American College of Emergency Physicians about career satisfaction and burnout published in 2009 likewise identified that 32% of doctors endorsed high levels of career burnout [11]. Burnout was significantly related to anxiety caused by diagnostic uncertainty and concern about potentially bad patient outcomes. Concerns about undiagnosed secondary headaches, dealing with drug-seeking behavior, and repeat visits by patients with persistent headache can add to the frustration of ED staff when caring for headache patients.

Some of the conflicts encountered in the ED may occur because patients and ED staff have different definitions of when patients should seek ED care. In an interesting study, adults shopping in supermarkets and malls were recruited for a survey, which was also completed by healthcare providers [12]. Responses were obtained from 1,018 lay people and 126 ED healthcare workers (Table 1.2). A significant difference of opinion identified between lay persons and ED workers was the feeling by lay persons (not shared by any ED workers) that having a medical problem outside of usual business hours represented a reason to seek ED treatment. Also, lay persons were asked to identify which of 30 chief complaints would require ED care. Lay persons and ED workers differed in their perceptions that severe headache would be considered an emergency condition. Interestingly, while 91% of ED workers identified severe headache as an emergency problem, only 58% of lay persons did so.

Table 1.2 Lay people and ED workers were asked to choose the best definition of an emergency medical condition (based on [12])

Pearl for the practitioner:

A substantial number of patients consider the occurrence of medical problems after hours to constitute an appropriate reason to seek ED care.

Common Traps Leading to Assessment Errors in Headache Care in the ED

Dr. Swadron from the ED at the University of Southern California recently published an article describing frequent pitfalls of headache management in the ED [13]. Commonly encountered pitfalls included problems with the assessment of headache patients (detailed below), misinterpretation of test results when ruling out secondary headaches, reliance on treatment options with a lower likelihood of good analgesic response (e.g., opioids), and failing to establish post-ED headache follow-up, especially for patients with primary headaches that would likely be expected to recur. Several of the most common traps identified as causes for error are detailed below.

Trap 1. Trying to Determine a Specific Primary Headache Diagnosis

The ICHD-II standard classifies headaches in a 149-page comprehensive reference with descriptions and diagnostic criteria for over 200 headache disorders, including over 40 individual primary headache diagnoses [4]. While providing an important anchor for headache research, this standard is too cumbersome and impractical for many busy clinical settings, especially the ED. The main focus of the ED headache assessment should be to distinguish patients with benign primary headaches from those with secondary headaches for which the condition causing the headache requires specific treatment.

In general, many of the same treatment principles and medications can be successfully utilized in patients with a variety of primary headaches. For example, both migraine and tension-type headaches share common clinical features and show similarly good response to medications, including drugs traditionally listed as “migraine-specific” therapies, such as the triptans [14]. In an interesting study, 480 patients with a primary ED complaint of nontraumatic headache not associated with altered mental status or malignancy were evaluated with a 100-item, standardized headache assessment interview based on ICHD-II criteria [15]. A total of 309 patients were determined to have a primary headache disorder (64%). Among these, the most common diagnoses were migraine (N  =  186, 60%) and unclassified headache (N  =  77, 25%). This study revealed that a specific headache diagnosis could not be identified for a substantial number of patients presenting to the ED with a primary headache disorder. These data underscore that it is more productive to rule out secondary headaches than to focus on which specific type of primary headache is present.

Pearl for the practitioner:

One in four patients determined to have a primary headache in the ED will be discharged without a specific headache diagnosis. Distinguishing primary from secondary headache is more important in the ED than establishing a specific primary headache diagnosis.

Trap 2. Making Diagnoses Contingent on Treatment Response

Primary headaches are diagnosed by clinical features and the absence of abnormalities on examination. Primary headaches cannot be diagnosed by treatment response. Patients experiencing headache relief from analgesics or the so-called migraine-specific medications may have migraine, but they may also have another primary headache or even secondary headaches. For example, two studies treating ED patients with sumatriptan, droperidol, or analgesics showed similar good efficacy in patients with migraine, tension-type headache, and primary headaches not meeting full criteria for a diagnosis of migraine [16, 17]. Triptans also can acutely relieve less common primary headaches, like cluster headaches [18]. Furthermore, sumatriptan has been reported to successfully relieve headaches due to a wide range of serious causes, including meningitis [19], subarachnoid hemorrhage [20, 21], carotid dissection [22], head and neck cancer [23], and others. Low pressure headaches, such as postdural puncture or spinal headaches, may also respond to treatment with the “migraine-specific” treatments, ergotamine and sumatriptan [24–26]. Although benefit from sumatriptan for postdural puncture headache has been shown in several case studies and is seen anecdotally in patients with persistent headache despite receiving an epidural blood patch, a small controlled study [N  =  10] of sumatriptan given to patients scheduled for epidural blood patch failed to confirm benefit [27].

Pearl for the practitioner:

Do not use treatment response to make a headache diagnosis. Serious, secondary headaches may be temporarily relieved with sumatriptan or other migraine therapies.

Trap 3. Failing to Recognize Secondary Headache

Chapter 3 is devoted to the topic of secondary headaches. Patients known to have a primary headache diagnosis may seek care in the ED due to an exacerbation of their primary headache or for a new, secondary headache. Secondary headaches are easiest to overlook in patients who frequently seek ED care for their established primary headaches.

Pearl for the practitioner:

A key question to ask is, “Why did this patient with chronic headaches present to the ED today?”

A question typically posed to patients presenting to the ED for headache is: “Is this your worst headache?” That question is intended to distinguish if the current headache is significantly different from usual headaches, possibly suggesting an important secondary headache. While this sounds straightforward, studies suggest that patient responses are often inaccurate and fail to correctly identify new or unusual headaches. In an interesting study, ED doctors at the University of New Mexico School of Medicine asked adult patients seen in the ED for a chief complaint of headache five questions, two of which related to headache severity and three of which were distracter questions [28]. The results of this study showed that asking about worst headache often produces inaccurate results (Table 1.3):

Table 1.3 Agreement between questions asked to 60 adult ED headache patients who were queried about headache severity (based on [28])

• Only 38% of those patients reporting that this was their worst headache not had a bad headache like this in the past, meaning it actually was their “worst headache.”

• 62% of patients reporting that this was the worst headache in their lives also gave an example of a similarly severe headache occurring in the past.

In some cases, patients may be saying that this is the worst headache because their previous headaches may have been of this same severity but never worse than the current headache. While attending to complaints of “worst headache” is important so that secondary headaches are not missed, merely hearing that this is the worst headache of the patient’s life does not mean that headache is necessarily due to an ominous cause. Additional questions to understand why this headache is considered “worst” are important.

Pearl for the practitioner:

Patients reporting having the “worst headache of my life” will need additional follow-up questions to accurately determine how the quality and severity of the current headache relates to previous headache episodes.

Trap 4. Failing to Identify Traumatic Headache

While nontraumatic headaches are usually benign, primary headaches, traumatic headaches generally require a more intensive work-up, including imaging studies of the head and neck. In some cases, trauma may be unreported (e.g., from abused children, abused or confused elders, or those with unwitnessed trauma). Suspicious behavior from caregivers or spouses, evidence of current or previous trauma, or an insufficient history may necessitate additional testing to ensure that unreported trauma did not contribute to the current headache complaints.

Trap 5. Failing to Address Hypertension Appropriately

Hypertension is often overlooked in the ED. In one study, only 57% of patients presenting to the ED with a blood pressure >140 mmHg systolic or 90 mmHg diastolic had their blood pressure reassessed during the same visit [29]. Patients were over twice as likely to have a repeat blood pressure when the ED had a blood pressure reassessment protocol. Furthermore, a survey of patients seen in the ED with severe hypertension (systolic blood pressure >180 mmHg or diastolic pressures >110 mmHg) showed that fundoscopic assessment was completed in only 36% of patients, blood work in 73%, an electrocardiogram in 53%, a chest x-ray in 46%, and a urinalysis in 43% [30]. These data show that hypertension is often incompletely assessed in the ED. With the utilization of electronic medical records in the ED, built-in decision support tools can remind clinicians to repeat elevated blood pressures and to perform a fundoscopic exam if blood pressure remains elevated.

Hypertension may occur comorbidly with primary headaches. Migraine sufferers are 40% more likely to have comorbid hypertension compared with headache-free controls [31]. Furthermore, patients with primary headaches occurring more than 15 days per month are twice as likely to have hypertension requiring treatment ­compared with patients with infrequent primary headaches [32]. Migraineurs are also at a significantly higher risk for cardiovascular disease and other risk factors, so identifying and treating hypertension in this population is particularly important (Fig. 1.4) [31].

Fig. 1.4

Odds ratios for cardiovascular risk factors and disease in migraineurs vs. controls (based on [31]). Odds >1 represent higher risk among migraineurs. Each variable was significantly increased in migraine sufferers

Pearl for the practitioner:

Hypertension should not be routinely attributed to headache pain. Elevated blood pressure should be repeated. Persistently elevated blood pressure will need to be explored directly.

During acute pain episodes, like severe primary headaches, patients may have an elevation in blood pressure. Whether the headache is caused by hypertension or blood pressure elevations are the result of severe head pain can be unclear. In an interesting study, patients with no history of hypertension who had an initial blood pressure at the ED >140 mmHg systolic or 90 mmHg diastolic and an elevated repeated pressure during the same visit were asked to monitor blood pressures at home twice daily for 1 week [33]. Among those patients with elevated blood pressures in the ED, 51% continued to record blood pressure elevations at home. Surprisingly, higher levels of pain or anxiety during the ED visit did not predict lower blood pressures once the patient was home. Therefore, hypertension during an ED headache visit should not be automatically attributed to pain.

The relationship of expected symptoms with elevated blood pressure has also been called into question. In a novel study, records from consecutive patients seen in the ED with hypertension were reviewed for the presence of typical hypertension-related symptoms [34]. Headache occurred in one-third of patients with hypertension, but headache was unrelated to blood pressure severity (Fig. 1.5). The only symptom that did occur significantly more often as blood pressure elevation increased was dyspnea, which was a chief complaint in 8% with stage 1 hypertension, 10% with stage 2, and 20% with stage 3 (P  =  0.004). See Table 1.4 for hypertension definitions [35]. In order to avoid incorrectly attributing elevated blood pressure to hypertension in patients for whom pain may be the cause of acute elevations, blood pressures should be repeated after pain-relieving treatments have been implemented and monitored throughout the ED visit.

Fig. 1.5

Headache is unrelated to severity of blood pressure elevations (based on [34]). DBP diastolic blood pressure, SBP systolic blood pressure. Blood pressure values are all mmHg

Table 1.4 Hypertension definitions (based on [35])

Pearl for the practitioner:

While the link between acute blood pressure elevations and head pain is unclear, identifying and arranging follow-up for hypertension in ED patients with headache may be especially important in migraine patients who are at significantly higher risk for cardiovascular disease than non-headache controls.

ED Visits for Headache Can Lead to Unnecessary Admissions

Although most nontraumatic headache visits to the ED are for primary headaches that will be discharged from the ED, an important and costly minority of these patients are admitted to the hospital. A large survey identified headache not related to trauma, inflammation, intracranial infection, increased pressure, or mass lesion, or other serious illness in 2% (N  =  80,500) of ED visits over a 1-year period in Singapore [36]. Among all of these headache patients, 18% were admitted, most commonly for diagnostic uncertainty and pain control (Fig. 1.6). Patients were admitted for an average of slightly more than 2.5 days, with a range from 1 to 35 days. Discharge diagnoses were most commonly migraine (29%), tension-type headache (25%), nonspecific headache (16%), and cervicogenic headache (8%). A potentially serious diagnosis was given to only 8% of patients, including hemorrhage, stroke, infection, hydrocephalus, seizure, and metastatic disease. These data support that, with better education, evaluation, and treatment protocols, and close follow up by headache-interested providers, many hospital admissions from the ED for headache might be avoided.

Fig. 1.6

Reasons for admission from ED for headache (based on [36]). Patients could endorse >1 reason

Pearl for the practitioner:

Hospitalization of headache patients from the ED occurs most commonly due to diagnostic uncertainty. Among those patients hospitalized, <10% are eventually diagnosed with significant pathology.

Streamlining the ED for Efficient and Effective Care of Headache Patients

The primary goals of ED headache management are to:

• Determine whether the headache is primary (usually migraine) or secondary. Making the specific diagnosis of which type of primary headache is less important.

  • Rule out important secondary causes of headache

  • Understand unique aspects of headache in children, pregnant and nursing women, and older patients

• Provide sufficient analgesia to reduce headache symptoms to a more tolerable level.

• Treat nausea aggressively.

• Develop an effective interim treatment plan with appropriate medications to last until the patient can see his/her outpatient healthcare provider.

• Facilitate post-ED follow-up care for ongoing headache complaints.

• Prevent unnecessary repeat ED visits for headache patients.

Consistently utilizing a streamlined approach to headache patient assessment and treatment can maximize effective treatment, improve staff and patient satisfaction, and minimize ED recidivism (Box 1.2).

Subsequent chapters will address these goals in greater detail and provide practical recommendations for the care of ED headache patients. Sample discharge instructions, including general information on primary headache management and headaches after minor head injury, are provided. Specific chapters will deal with special populations of patients including children and adolescents, pregnant and lactating women, and the older adult with headaches. By using simple and practical assessment and treatment tools, including questionnaires and clinical algorithms, headache patients can be efficiently and effectively treated in a busy ED. The practical tools contained in the book may be photocopied from the pages of this book or downloaded from http://extras.springer.com/. You may also be linked directly to these downloads through a link at http://www.dawnmarcusmd.com.

Box 1.2 Tenets of Headache Care in the ED

• 1. ED staff should recognize that patient concerns prompting an ED visit for chronic headache may conflict with their own view of what constitutes the need for emergency care.

• 2. Headache patients should be provided with compassionate care delivered as promptly as possible.

• 3. A focused history and physical, including a good screening neurological exam, can direct the need for additional testing.

• 4. The headache assessment should include consideration of rare secondary causes of headache.

• 5. Distinguishing primary from secondary headache is more important than trying to clarify which specific primary headache diagnosis should be assigned to an individual patient.

• 6. Selective use of imaging procedures and other testing should be used to rule out rare, secondary causes of headaches.

• 7. Patients with protracted, primary headaches often need to be rehydrated.

• 8. Nausea should be treated aggressively.

• 9. Headache-specific treatments and effective nonopioid analgesics should be used to target headache pain, without an over-reliance on narcotic medications. In general, opioids should not be routinely used as part of an interim treatment strategy after ED discharge as other effective, less problematic options are available.

• 10. Clear, written, take-home instructions should be given to patients to describe: how to manage continuing or recurring headaches; how to contact a primary care provider or other headache-interested provider for ongoing care; and when to return to the ED.

• 11. Patient instruction sheets on general headache treatment and prevention tips should be provided to help facilitate effective self-management of chronic headaches to minimize reliance on the ED for headache symptoms.

• 12. Follow-up should be arranged with a primary care provider or headache-interested doctor within 1–2 weeks of ED discharge.

Summary

• Nearly two of every three patients evaluated in emergency settings for nontraumatic headache will be diagnosed with a benign or primary headache disorder, usually migraine.

• A specific primary headache diagnosis will not be able to be determined for one in four patients with a primary headache seen in the ED.

• Secondary headaches in the ED are more common in middle and older aged adults, especially those >75 years of age.

• ED care of migraine is expensive, costing nearly $2,000 per patient visit. Many of these visits – especially repeat visits – can be avoided with a good interim treatment strategy and outpatient headache care.

• Assessment errors commonly encountered in the ED management of headache include:

  • Spending too much time to determine which type of primary headache should be assigned

  • Using treatment response to determine a headache diagnosis

  • Not understanding the meaning of reports of the “worst headache of my life”

  • Failure to identify unreported trauma

  • Failure to appropriately address hypertension

• Nearly half of all hospital admissions for headache from the ED are caused by diagnostic uncertainty. A well thought out approach to evaluation of the patient with an acute headache can reduce admissions related to diagnostic uncertainty.

• Only 8% of patients hospitalized for headache from the ED are eventually diagnosed with significant pathology.

• Patients – but not ED staff – often consider having symptoms outside of business hours to constitute an indication for ED care.

• Improving access to and utilization of outpatient primary care or other headache-interested providers may substantially reduce unnecessary repeat ED visits for acute headache treatment.