Do you know how to tell which headaches are life-threatening?
Don’t miss life-threatening causes of headache; recognize danger signs and know key questions to ask
Patients who complain of headaches represent 1-2% of ED visits and present a unique challenge: They may be in need of Tylenol or could require life-saving surgery.1 "At triage, your goal is to figure out whether this is one of the 97-98% of patients who have a benign cause of headache, in which case you’ll give them prompt pain relief and get them discharged," says Michael Callaham, MD, FACEP, professor and division chief of emergency medicine at UCSF Medical Center in San Francisco. "Or is it one of the 2-3% who have a life-threatening cause of headache, in which case you focus on diagnostic workups and get them into the [operating room] OR or wherever they need to be."
Determining if there is an underlying problem is paramount, stresses Ann Dietrich, MD, FACEP, an emergency department (ED) physician at Children’s Hospital in Columbus, OH. "CT scans are an important diagnostic tool, but subarachnoid bleeds may not be detected on a CT scan. A lumbar puncture or [magnetic resonance imaging] MRI may be necessary," she says. "The CT scan also does not do a great job of imaging the posterior fossa, so the patient may also require an MRI. Lumbar punctures are diagnostic of meningitis."
There is a tendency to minimize the seriousness of headaches, but that is a mistake, stresses Michael Gerardi, MD, FAAP, FACEP, vice chairman of the department of emergency medicine at Morristown Memorial Hospital (NJ). "People with headaches come to the ED because they have severe pain, they are scared, and they have nowhere else to turn," he says. "There is a lot we can offer these patients, but our major role as ED nurses and physicians is to determine whether the patient has a life threatening condition."
Here are the signs present if a headache is a life-threatening condition:
Explosive onset. "If a patient suddenly gets hit with an explosive headache and describes the onset as boom, like a thunderclap,’ that is very suggestive of a subarachnoid bleed," says Callaham. "That’s not the story you will get for migraine and most other kinds of headaches."
"It’s the worst headache of my life." "If a patient tells you it’s the worst headache of their life, or if they say this is a completely different kind of headache,’ those are key phrases that force you to go looking for pathological causes," says Callaham. "Those words alone often mean you have to get a CT scan and lumbar puncture."
Severe pain is an ominous sign, says Patricia Masson, RN, MSN, clinical systems facilitator at Massachusetts General Hospital and Partners Neurology at Brigham & Women’s Hospital in Boston, MA. "We have pain receptors within our meninges and our trigeminal trunk," she notes. "Patients with ruptured aneurysms or subarachnoid hemmorhages are usually the ones who will complain of severe pain—the worst headache of their life."
The patients may have had migraines all their lives, but pay attention if they tell you that this one feels different, says Callaham. "If they say I’ve never had anything that came close to this,’ then you can no longer assume it’s the same cause. You need to start looking for one of the malignant causes of headache," he explains.
Ask the patient what makes the headache different, advises Callaham. "The pain may be the most severe, but is this the same kind of pain or pattern as the other migraines?" he asks. "They may say, it never lasted this long, or they’ve thrown up once before, but this time they threw up four times. If you get that clear-cut story where it feels the same but is just much more severe, in that case you can say it’s probably still the migraine."
But the patient may insist the headache feels different than other migraines. "They may say, I’ve had a lot of migraines but this feels different, not just more severe—there is something different about this just doesn’t feel like a migraine.’ And usually they are right," says Callaham. "The headache may be something obviously different and you have to proceed accordingly."
Neck stiffness. "This suggests irritation of the meninges, which could be due to either meningitis or blood in the cerebral spinal fluid, so, in either case, there is something serious going on," says Callaham. Headache with neck pain is also associated with subarachnoid bleeds, he adds.
Children. "Migraines in kids under the age of 8 or 9 are pretty unusual. So if a 3-year old comes in and says they have a headache, you have to be concerned about that," says Gerardi.
Cancer. "People get metastases to the brain pretty frequently. So if a patient has breast cancer and shows up one day with a tremendous headache they have never had before, there is good reason to be worried," says Callaham.
Anticoagulated patients. "If a patient is anticoagulated and comes in with a headache, you should be very suspicious, unless you can prove their coagulation times are normal," says Callaham. "One of the places you can bleed is in your head, which is a particularly dangerous place for bleeding."
This requires little or no head trauma, Callaham notes. "It could be so minor the patient doesn’t even realize they’ve done something," he says. "They may have banged their head on the bedpost two days ago and didn’t feel anything, but now they have this headache."
Immune suppressed patients. When an immunosuppressed patient comes to the ED with a headache, it needs to be treated as a serious matter. "Particularly patients with AIDS, but also cancer patients because a common site of infection is the central nervous system," says Callaham. "They might have an infection in the brain but don’t necessarily show neck stiffness, fever, or anything else, so they are high-risk patients."
Neurological symptoms. "If a patient has neurological symptoms with a headache, you have to wonder if something is going on with the brain that is impairing its function," says Callaham. "Be concerned about any alteration of consciousness, even if they are just groggy or sleepy. That is something which almost guarantees a CT scan."
Elderly patients. "The age of the patient determines the likelihood of certain disorders," notes Callaham. "With an older patient, you are more concerned about stroke. A 70-year-old patient with the first headache of their life is not too likely to have a migraine."
Post-coital headaches. "You always worry about headaches that are associated with intercourse, because that is a common time for aneurysms to rupture," says Masson.
Fever. "Any patient who presents with headache and fever or rash should absolutely and immediately be placed in a treatment area, because you should be worried about the presence of meningitis," says Gerardi.
Here are some things to consider when managing patients with headaches:
Observe how patients change over time. "Patients who have had an event will get worse, as opposed to traditional migraine patients," Masson explains. "At triage you may see a droopy face, but an hour later they are becoming sleepy and their face is very droopy. Their baseline at triage could worsen in as short a period of time as 15 or 30 minutes."
However, observation is not reliable for subarachnoid bleeds, Callaham emphasizes. "A person with a small sentinel bleed will get better, lulling you into a false sense of security," he says. "This is your chance to make the diagnosis before the aneurysm really blows out in a week or two."
Give headache patients a journal. "I encourage ED nurses to develop a journal that they can give to patients, so they can identify headache patterns," says Masson. (See sample headache diary inserted with this issue.) "Tell patients to think about what their triggers are. It could be eating bananas, chocolate, or white onions, or being around people with perfume on."
Patients who keep such journals can eliminate triggers, Masson says. "It’s amazing how dramatically headache incidence drops after keeping a journal," she notes. "Often, people are just reacting to the pain syndrome and haven’t thought about it in a preventative mode."
Work with other physicians to manage headache patients. "Identify a neurologist in the community and work with them to develop a game plan for how to manage these patients," Masson says. "For example, a lot of patients are being treated with drugs that aren’t going to help them when a headache gets out of control. They need a plan to abort the headache and know the rules for when they can come to the ED."
Consider unique needs of pediatric patients. Headaches are an unusual complaint in the pediatric population, says Dietrich. "Serious diseases that should be considered include meningitis (fever, stiff neck, and headache), hydrocephalus (usually the children have already been diagnosed and have a VP shunt in place and the concern with a headache is a dysfunction), brain tumors (uncommon, usually associated with headaches that wake the child from sleep, vomiting, and ataxia or other neurologic changes), and bleeds," she notes.
Consider impact of pregnancy on migraines. "Migraines do get better with pregnancy, but not until the second trimester," says Masson. "During the first trimester, the patient may have one headache after the other. Hormones are a big influence on headaches, so that is a group of patients you need to consider."
Many headaches are hormonally related, Masson notes. "Birth control pills can make them worse or better, and can either prevent migraines or cause severe headaches," she says. "We are also seeing an increase in incidence in the perimenopausal population, which seems to be hormonally related. So a [female] headache patient in her 40s should probably see her gynecologist to find a way to retard the increase in headaches."
Birth control pills increase the risk of dural venous thrombosis, Callaham notes. "This is a very dangerous and particularly difficult to diagnose type of headache," he adds.
Don’t underestimate the value of sleep with migraines. "Sleep is critical and patients have got to lie down in a quiet room," stresses Gerardi.
Follow-up with patients to see how they’re doing when not in pain. "Explain that we are concerned with the possibility of the patient becoming a transformed’ headache patient, going from two or three times a month to chronic, daily headaches," advises Masson. "That can be initiated with many of the drugs we give, and even with over-the-counter drugs, such as ibuprofen. Those patients need to be on chronic daily prevention."
Encourage patients to be their own care managers. "Patients need to follow a collaborative care program, which may include avoiding identified food or environmental triggers, and taking preventive drugs every day," Masson explains. "Then, when they do have an exacerbation, they take a certain drug four times, one hour apart. If, by the 3rd or 4th time, it’s still not effective, they may take a rectal suppository. Ninety-nine percent of them will break at that point."
If the plan is followed and the headache has not gotten better, then an ED visit is appropriate, says Masson. "You always worry about a migraine not responding to the treatment plan, because there may be something else going on. So you would want to see the patient then," she explains.
Teach patients to abort a headache before it starts. "Some know when a headache is coming on, but instead of treating it immediately, they wait 30 minutes too long and it’s too late," says Masson. "At that point, all the things we’ve given them to abort headaches will be totally ineffective because they have an ileus now, which is why they vomit."
Patients must have a comprehensive treatment plan to reduce ED visits, says Masson. "The first line of action may be to take a couple of Imitrex when they feel like something is coming on. Maybe the next line is a rectal suppository," she notes. "Deep sleep often promotes migraine relief."
Explain what to expect from diagnostic procedures. "Nurses should explain that lumbar puncture is a minimally invasive procedure and is mildly painful, and that it is necessary to rule out meningitis, encephalitis, and subarachnoid hemorrhage," says Gerardi. "Many people hear the words spinal tap’ and they go ballistic. We should explain that it is a five-minute procedure, with four minutes of preparation and approximately one minute for the procedure," he explains.
Be familiar with new management approaches. "The new serotonin 5HT1d receptor agonists are very selective and they go right to the cause of the headache, so they are much better drugs," says Gerardi. "It’s an exciting time for the treatment of migraines, and also cluster headaches. The old ergots that worked on these receptors were not selective, and, therefore, also caused nausea and other symptoms."
Another advantage is that the agents can be taken at any time. "The original ergots had to be taken at the onset of the headache in order to work, but these can be taken at any time, even a day or two into the headache," says Gerardi. "There are multiple delivery vehicles, including oral tablets, nasal sprays, and injections," he notes.
The drugs also last longer. "The newer agonists are longer acting than Imitrex, which would wear off in a few hours and you’d need to take another one," Gerardi says.
However, the older serotonin antagonists (DHE) are effective after the onset of headaches, Callaham notes. "There are multiple, randomized controlled trials showing they are just as effective at the same time in the headache evolution as Imitrex and newer drugs," he says.
Another advance is prophylactic medications, such as tricyclic antidepressants, aspirin, betablockers, calcium channel blockers, and magnesium. "These are being used more frequently as prophylaxis against migraines," Gerardi reports.
1. Rakel RE. Conn’s Current Therapy. Philadelphia, PA; WB Saunders; 1997.