Evaluation and Management of Headache in Emergency Department

Headache is not an uncommon complaint in emergency department constituting at least 2 percent of emergency department (ED) visits. Although majority of these headaches are benign, the small proportion of life-threatening headaches should be diagnosed and managed emergently. There are a number of factors that make the topic of headache in ED as an important issue in neurology. The serious life threatening etiologies in some patients with headache presenting to ED ,the different assessment and management of primary and secondary headache in ED and severe pain management are among these factors. To differentiate the serious headache from the benign one, a precise history and physical examination is the most fundamental part of the evaluation. Features with high risk in history include headache with sudden onset, the most severe headache so far, any other systemic comorbidity, loss of consciousness, seizure, age more than 50, immunosuppression, visual disturbances in addition to pregnancy and postpartum state. Drug and habitual history have an important role in headache history as illicit drugs and toxic exposure can cause life-threatening headache. In physical examination, high-risk findings are unstable vital signs, neurologic abnormalities and ophthalmologic findings. In Patients with history of prior headaches who present to the ED without any high-risk feature according to history and examination, an extensive diagnostic assessment in the ED seems not necessary. In high-risk patients, further evaluation should be performed to diagnose the underlying cause. Laboratory tests, imaging, and lumbar puncture for cerebrospinal fluid might be considered. In addition to detecting the etiology of headache, management of the severe head pain in patients presenting to the ED is very important. Relieving the pain without causing drowsiness is the goal of treatment. Treating nausea and vomiting should also be considered. In some studies, ketorolac, prochlorperazine and chlorpromazine have been used effectively.