Karl E. Misulis, MD, PhD
CHAPTER CONTENTS
OVERVIEW
Most headaches are managed in an outpatient setting. However, patients with severe headache, intractable headache, or headache with atypical features will present to the ED and might be admitted.
Proposed criteria for admission:1
•Prolonged unrelenting headache with associated symptoms, such as nausea and vomiting, hindering daily activities
•Concern for a possible secondary etiology, such as infection (abscess or meningitis) or an acute vascular process (stroke, subarachnoid hemorrhage, aneurysm, vasculitis)
•Status migrainous with dependence on opiates or other analgesics, barbiturates, triptans, or ergots
•Intractable headache that requires dihydroergotamine (DHE)
•Treatment with medications with potential side effects requiring monitoring
When laying out a potential treatment plan, it is important to investigate reasons for worsening headache. It is also important to develop and agree to a realistic treatment goal at the time of admission. Most patients will not be headache-free at the time of discharge.
The possible causes of refractory headache are multiple:
•Concomitant medical issues causing headache
•Wrong therapeutic choice for headache type
Unrealistic expectations from the patient’s perspective (expecting total headache freedom) can also make headache seem “refractory” when indeed therapies have been beneficial.
Most headaches encountered on an inpatient basis are migrainous in nature. Differential diagnosis and appropriate workup should be considered, and these are detailed in Chapter 10.
MIGRAINE
Migraine patients seen in the ED or inpatient setting can be administered meds not available on an outpatient basis. Treatments address pain, associated nausea and vomiting, and, if possible, underlying precipitating factors.
Patients with medication overuse headache should be withdrawn from the offending medications, if possible, and started on preventative therapy.
Clinical Disorders
Migraine is clinically subdivided on the basis of associated symptoms. Common clinical features include headache, which can be unilateral, regional, or holocephalic. Character is often throbbing but can be steady, and there may be a sharp component to the pain. Associated symptoms that support the diagnosis of migraine include nausea or vomiting, photophobia, phonophobia, and possibly an aura.
Migraine with Aura
Migraine with aura or classic migraine is a typical migraine preceded by an aura of neurologic symptoms. Common symptoms include:
•Visual: Scintillating scotoma or field defect
•Sensory: Numbness or tingling on one side
There are other potential auras, such as confusion or language difficulty; these are less common, but when they occur, they are likely to be seen in the ED.
Typical of the aura is “marching” of the symptoms. The visual defects move across the visual field. Sensory symptoms march through the limb. If more than one symptom is manifest, they are often not synchronous, transitioning from predominance of one modality to another within a single episode. This temporal evolution helps to differentiate migraine aura from stroke.
DIAGNOSIS is usually clinical, but, with the aura, patients may come to the ED for evaluation of possible stroke. If there is no history of prior migraine or aura, then neurologic evaluation will be needed. Magnetic resonance imaging (MRI) of the brain with MR angiography (MRA) is appropriate.
MANAGEMENT is in common with migraine, in general, with abortive therapy for patients with acute migraine. Preventative therapy is used when frequency and severity make even effective abortive therapy insufficient.
Migraine without Aura
Migraine without aura or common migraine has the same general character as migraine with aura, but there is no aura. Also, migraine without aura is more likely to be bilateral.
DIAGNOSIS is clinical, and, in the absence of neurologic symptoms, appearance in the ED and necessity for diagnostic studies is less. However, severe headache when it first occurs may trigger evaluation for subarachnoid hemorrhage or other serious pathology.
MANAGEMENT is as for other migraines, described in the following sections.
Hemiplegic Migraine
Hemiplegic migraine presents with an aura of unilateral paralysis. The weakness usually develops prior to the headache. Hemiplegic migraine is often familial.
Complicated Migraine
Complicated migraine is an otherwise typical migraine headache in which there is prolonged neurologic deficit. The deficits usually start before the headache and outlast the headache by at least several hours or a day.
Migraine Equivalent
Migraine equivalent is a term commonly used for neurologic symptoms that have the character of an aura but without headache. Therefore, this is in the differential diagnosis of acute focal symptoms and signs.
DIAGNOSIS is suspected when a patient has deficit that marches, as is typical with an aura.
Migrainous Infarction
Migrainous infarction is acute ischemic stroke in the setting of a migraine headache. The neurologic deficit thought initially to be aura persists. MRI shows acute ischemia.
DIAGNOSIS is usually initially suspected as being migraine-with-aura or hemiplegic-migraine or perhaps complicated-migraine, depending on the stage of the symptoms at the time of ED presentation. MRI shows acute ischemia.
Acute Therapy
Approaches to management of migraine are abortive therapy and preventative therapy. Attention to medical issues is of particular importance for migraine patients seen in the ED or hospitalized. Often, patients are dehydrated, and replacement of fluids can be an important part of management. Acute therapy includes
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