philip bossart, md 1 headache treatment: what’s the latest?

Philip Bossart, MD1

Headache Treatment: Headache Treatment: What’s the Latest? What’s the Latest?

Philip Bossart, MD2

Philip Bossart, MD

ProfessorDivision of Emergency Medicine

University of Utah College of MedicineSalt Lake City, Utah

Philip Bossart, MD3

Session ObjectivesSession Objectives

• How to Diagnose Life Threatening Causes of Headache

• How to Diagnose Migraine Headaches

• How to Treat Migraine Headaches in the ED

CartoonCartoon

Philip Bossart, MD5

Clinical CaseClinical Case• 20 year old female has a chief complaint

of headache. HA started 6 hours ago. Similar but milder HAs in the past. Prior headaches resolved with ibuprofen and rest but not today’s. Pain is bilateral, 10/10 intensity, with photophobia and phonophobia. She noted blurry vision before headache. Denies nausea, fever, focal weakness or numbness. She is late for her period.

Philip Bossart, MD6

Case Presentation (cont’d)Case Presentation (cont’d)

• Her exam shows a BP of 120/80, HR of 70, RR of 20 and she is afebrile. She is alert and Ox3 but is in significant distress from pain. Scalp is tender, pupils 2 mm and reactive. Heart, Lung, and Abdominal exam are normal. GCS is 15. Cranial nerves and motor, sensory cerebellar and DTR testing is all normal.

Philip Bossart, MD7

Case Presentation (cont’d)Case Presentation (cont’d)

• What tests need to be performed if any?

• What is the most likely diagnosis?

• How should she be treated?

Philip Bossart, MD8

Key Clinical QuestionsKey Clinical Questions

• What are the life threatening causes of acute headache?

• What are the “red flags” which suggest a serious secondary HA?

• What are the IHS criterea for migraine?

Philip Bossart, MD9

Key Clinical Questions Key Clinical Questions (cont’d)(cont’d)

• How should migraines be treated in the ER?

• What are the contraindications to Triptans and DHE?

Philip Bossart, MD10

Life Threatening Causes of HeadacheLife Threatening Causes of Headache

• Intracranial bleed (esp. SAH)

• Meningitis

• Carotid or vertebral dissection

• Sinsus thrombosis


Other Serious Secondary HAsOther Serious Secondary HAs

• Mass lesions, intracranial hypertension, temporal arteritis, hypertensive encephalopathy, hypoxia, hypercapnea, CO toxicity, glaucoma


What are the “red flags” which What are the “red flags” which suggest a serious headache?suggest a serious headache?

• Thunderclap headache: SAH, vascular dissection, venous thrombosis, pituitary apoplexy.

• Headache onset during exertion: SAH or dissection

• HIV and Immunosuppression: infections and tumors


““Red Flags” (cont’d)Red Flags” (cont’d)• New onset headache over age 50: mass

lesions and temporal arteritis

• Any neurologic sign or symptom: This is the best predictor of intracranial pathology. Look for papilledema, Horner’s syndrome, glaucoma. (Exception is typical migraine aura.)


““RED FLAG” MnemonicRED FLAG” Mnemonic“S N O O P S”

SSYSTEMIC SYMPTOMS (e.g. fever,weight loss)

NNEUROLOGIC SYMPTOMS/SIGNS

OONSET (SUDDEN)

OOLD AGE (50 YEARS)

PPRIOR HISTORY (New Headache)

SSECONDARY ILLNESSES (AIDS, CANCER)


What are the IHS criterea for What are the IHS criterea for diagnosing migraines?diagnosing migraines?

• At least 5 episodes• 4 to 72 hour duration• At least 2: unilateral location;

pulsating; moderate to severe; aggravated by activity

• At least 1: nausea and/or vomiting; photophobia and phonophobia

• History and Exam do not suggest another diagnosis


How should migraines be How should migraines be treated in the ER?treated in the ER?

• Migraine specific medications (triptans, DHE, phenothiazines) are preferred

• Parental route if severe, long standing, or vomiting.

• Many medication choices without good data on best one to use


Migraine Treatment (cont’d)Migraine Treatment (cont’d)

• Phenothiazine

• Triptan or DHE

• Ketorolac

• Valproic Acid

• Narcotics


Migraine Treatment (cont’d)Migraine Treatment (cont’d)

• Prochlorperazine 10mg IV or Metachlopramide 10mg IV, Followed by: DHE 1mg IV if nec.

• Sumatriptan 6mg SQ followed by phenothiazine if nec.

• Some add diphenhydramine 25mg IV to phenothiazine to prevent akasthesia


Migraine Treatment (cont’d)Migraine Treatment (cont’d)• Ketorolac 30mg IV or IM• Chlorpromazine .1mg/kg IV (diluted

in 20 cc saline) watch for hypotention

• Valproic acid 500mg to 1000mg IV• Intranasal Lidocaine• Narcotics


What are the contraindications What are the contraindications to Triptans and DHE?to Triptans and DHE?

• Widely used medications with excellent safety profile

• Chest pain is common but not serious and is not necessarily ischemia


Contraindications to Contraindications to Triptans and DHE (cont’d)Triptans and DHE (cont’d)

• Known CAD or CVD

• Uncontrolled hypertension

• Pregnancy

• Hemiplegic or basilar migraine

• Within 24 hours of prior use


Case ConclusionCase Conclusion

• No red flags

• CT scan not indicated

• The only lab test done was a pregnancy test which was positive

• Diagnosed with “migraine with aura”


Case Conclusion (cont’d)Case Conclusion (cont’d)

• Pregnancy reduces migraines in most patients but may get worse

• Triptan and DHE contraindicated since she is pregnant

• Treated with Prochlorperazine 10mg IV with prompt relief of HA


Case Conclusion (cont’d)Case Conclusion (cont’d)

• Since she was pregnant and had infrequent attacks, no preventive medications were given

• Discharged home with OB folllow up.


Questions??Questions??www.ferne.org

[email protected]

Philip Bossart, [email protected]

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philip bossart, md 1 headache treatment: what’s the latest?

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