Headache is a common complaint in the emergency department (ED) and can range from benign to life-threatening conditions. As a junior doctor in emergency medicine, it is crucial to differentiate between primary headaches, which are generally less serious, and secondary headaches, which may indicate underlying pathology requiring urgent intervention.
Types of Headaches
Primary Headaches
These are not associated with other diseases and include:
Tension-type Headaches: Characterized by a dull, aching sensation often described as a tight band around the head.
Migraine: Typically unilateral, pulsating, and can be associated with nausea, vomiting, and sensitivity to light or sound. Some patients experience aura before the headache onset.
Cluster Headaches: Severe, unilateral headaches often around the eye, accompanied by autonomic symptoms such as tearing or nasal congestion.
Secondary Headaches
These result from underlying medical conditions and require prompt evaluation:
Subarachnoid Hemorrhage (SAH): Sudden onset of a severe headache often described as "thunderclap" or "worst headache of my life." It may be associated with neck stiffness, photophobia, or neurological deficits.
Meningitis: Presents with headache, fever, neck stiffness, and photophobia. Consider if there is a history of recent infection or immunocompromise.
Intracranial Masses: Headache may be associated with neurological symptoms such as seizures or focal deficits.
Temporal Arteritis: Typically affects older adults and presents with a unilateral headache, scalp tenderness, jaw claudication, and vision changes.
Acute Glaucoma: Severe headache with eye pain, blurred vision, and halos around lights.
Initial Assessment and Management
History Taking
A thorough history is essential to guide further evaluation:
Onset and duration of the headache
Location and character of the pain
Associated symptoms (e.g., nausea, visual changes)
Previous history of similar headaches
Recent trauma or infections
Medication use and changes
Physical Examination
The physical examination should focus on identifying signs that may indicate specific causes:
Neurological examination: Assess for focal deficits or altered mental status.
Fundoscopic examination: Check for papilledema.
Neck examination: Evaluate for stiffness or meningism.
Diagnostic Workup
Depending on clinical suspicion from history and examination, the following tests may be considered:
CT Scan of the Head: To rule out hemorrhage or mass lesions.
Lumbar Puncture: If meningitis or SAH is suspected but CT is negative.
Blood Tests: Including complete blood count (CBC), electrolytes, and inflammatory markers like ESR if temporal arteritis is suspected.
Management Strategies
Management of headaches in the ED focuses on addressing both symptom relief and underlying causes:
Symptomatic Treatment:
Analgesics such as NSAIDs or acetaminophen for tension-type headaches.
Triptans for migraines if no contraindications exist.
Specific Interventions:
Immediate referral to neurology or neurosurgery for suspected SAH or intracranial masses.
Antibiotics for suspected bacterial meningitis initiated promptly after obtaining cultures.
Monitoring and Follow-up:
Continuous monitoring for any deterioration in neurological status.
Referral to specialists for chronic or recurrent headaches requiring further evaluation.
Challenges and Considerations
Headaches can be challenging due to their broad differential diagnosis. It is crucial to identify red flags that suggest secondary causes requiring urgent intervention. These include sudden onset ("thunderclap"), neurological deficits, altered consciousness, fever with neck stiffness, and visual disturbances.
By taking a systematic approach to the assessment and management of headaches, you can effectively address this common complaint in the emergency setting while ensuring appropriate follow-up care.
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