Can’t Miss Diagnoses
- Intracranial Hemorrhage (ICH) – subarachnoid hemorrhage
- Traumatic ICH – Subdural hematoma, Epidural hematoma
- Increased ICP: Story of Shunt, malignancy, Cushing’s response
- Meningitis, Encephalitis
- Status Migrainosis
- Early COVID-19 may present with headache, myalgias (early viral symptoms)
- Cerebral Venous sinus thrombosis (CVST)
- Vascular: Temporal arteritis/Giant-Cell Arteritis, Carotid artery dissection
- Eye: Acute angle-closure glaucoma
- Carbon Monoxide (CO) poisoning
Mnemonic for Dangerous Headaches
B – Bleed (SDH, EDH, SAH)
I – infection
T – Thrombosis
E – Eye
M – Mass, Migraine (Esp Status Migrainosis)
E – Environmental exposures (CO poisoning)
Non-Emergent but Common Headaches
- Trigeminal neuralgia
- Post-traumatic (concussive)
- Post-Lumbar Puncture Headache
- Cluster or Histamine Headaches
- Dental problems
- Tension Headache
- Cervical Strain
- Effort-dependent or coital headaches
Points to focus upon
History of Trauma, Anticoagulation, Maximal intensity at onset, Fever, immunocompromised.
- Full neuro exam and reassess
- Check for signs of meningismus, temporal tenderness, Eye exam, signs of raised ICP
Remember to document the presence or absence of red flags and neuro findings.
- CBC, BUN, Cr, Lytes, Glucose
- Consider INR/PTT (esp if on warfarin or DOACs)
Remember, diagnosis of EXCLUSION for benign causes.
Use CT Rules to guide the choice to get a CT Head if possible.
Clinical Decision Tools
- Canadian CT Head Rules
- PECARN head injury rule for children
- Ottawa Subarachnoid Rule
- “6-hour CT head for r/o SAH” rule – not an official rule, but mounting evidence
Management for ICH would usually involve Neurosurgery and/or admission.
Consider reversal of oral anticoagulation using human prothrombin complex (PCC) in consultation with hematology/thrombosis/Blood bank to your institution.
Specific reversal agents are also available, but consult your hematologists or local protocols for this.
ED Migraine Management:
In addition to acetaminophen and NSAIDs (e.g. Toradol 10mg IV x1), there is some evidence for the use of dopaminergic agents for the resolution of migraines, including but not limited to: metoclopramide (trade name: Maxeran), haloperidol (trade name:Haldol). The side effect to watch out for with both would be akasthesia which can be precipitated by either. [Pro-tip: The antidote for these akasthesias is IV diphenhydramine (i.e. Benedryl).]
Discharge Diagnoses to Educate About:
Migraine, Tension HA, Cluster HA, ENT referred pain
Patient Education Materials
- Alberta Health Services Choose Wisely Infographic: See Figure 1
- PECARN Education Card (by ALiEM-CanadiEM)
Recommended reading, videos, and podcasts
- Approach to: Headaches
- CRACKCast E020 – Headaches (General approach)
- CanadiEM MVP infographic – CT Head Rules Infographic
- CRACKCast E103 – Headache Disorders (Deeper dive)
- EMCases Headache Pearls and pitfalls
- Canadian CT Head Rule YouTube Video (featuring Dr. Stiell himself)
Also see “CanadiEM Frontline Primer – Trauma – Isolated Head Injury” for similar info.
This post was copyedited and uploaded by Evan Formosa.