Headache patients – what do you do first?
In the emergency room setting, the most important part of an evaluation is focused history and physical exam to look for ‘red flags’ which can clue you into a more serious etiology. By the same token, if ‘red flags’ are not present, your charting should include the fact that you asked about these factors and that they were not present.
Examples of things that should make you seriously consider a more serious, secondary cause of a headache include:
- Sudden onset (as opposed to progressive gradual onset)
- The worst headache a person has ever experienced
- Trauma
- Associated seizure
- Fever
- Neck pain or meningismus
- Altered mental status
- No prior headache history or change from baseline
- Elderly
Treating associated symptoms
Before considering pain relief, remember to treat a patient’s associated symptoms. Many patients with a headache will also experience nausea, vomiting, and dehydration. Inserting an IV and giving a fluid bolus along with anti-emetics can help significantly.
‘Migraine cocktail’
One of the first-line treatments for patients with migraines is reglan (metoclopramide). When used in combination with toradol (ketorolac), the ‘migraine cocktail’ has been made complete. Decadron (dexamethasone) is great for preventing recurrence in the next 72 hours and is something I personally administer to almost all patients with suspected migraine.
Antihistamines like benadryl (diphenhydramine) don’t have great support in the literature but are often requested by patients. They can cause sedation but likely don’t help much with analgesia.
Side effects
Be mindful that some of these medications can cause QT prolongation and that patients may be on other medications which can also have this effect.
Phenergan (promethazine) is another good alternative that has shown success in pain and nausea relief – however it should not be given IV and may also cause QT prolongation so should not be routinely used in combination with reglan.
Any other options?
Tons! Nerve blocks, oxygen, magnesium, ketamine, etc. Opioids are not highly recommended but use your best judgement.
