Headaches
Although most headache presentations to the ED are of benign etiology, there are several potentially life-threatening conditions for which the emergency physician should have a high index of suspicion based on symptoms. This special feature reviews migraine, thunderclap headache, and uncommon—but potentially serious and life-threatening—causes of headache.
Sumatriptan
Subcutaneous sumatriptan is highly effective in treating migraine quickly, with a median time to relief of 34 minutes.8 The triptans, however, are not appropriate for all patients. Due to the high rate of side effects associated with sumatriptan, including palpitations, flushing, and chest pressure, it is contraindicated in those with cardiovascular (CV) risk factors.
Although effective in relieving migraine, there is a 67% rate of headache recurrence after successful initial treatment with subcutaneous sumatriptan. Therefore, along with counseling patients about side effects of the drug, EPs should also advise them of the high probability of recurrence and discharge patients with medication in anticipation of rebound headache. Table 3 lists the currently available triptans, along with routes of administration and recommended doses.
Ergotamines and Antiemetics
In addition to sumatriptan, dihydroergotamine, administered with an antimigraine antiemetic such as prochlorperazine, is another highly effective treatment option. Since the ergotamines have vasoconstrictive and oxytocic effects on the placenta and may cause harm to the fetus, they are rated Category X. As with sumatriptan, these agents are appropriate for use in nonpregnant patients and patients who have no CV risk factors.
Nonsteroidal Anti-inflammatory Drugs
Parenteral NSAIDs may also be considered to treat acute migraine. A recent meta-analysis of ketorolac for acute migraine showed it to be as effective as meperidine and the phenothiazines and more effective than intranasal sumatriptan.9 Side-effect profiles among the drugs were similar; however, it was common for patients receiving ketorolac to require rescue medications more frequently than patients receiving alternative medications for migraine. Given these findings, it is more appropriate to use ketorolac as a second-line—rather than first-line—agent for the treatment of acute migraine.
Antiemetic Dopamine Antagonists
Antiemetic dopamine antagonists such as metoclopramide, prochlorperazine, and droperidol are effective antimigraine agents. Intravenous metoclopramide and prochlorperazine have outperformed subcutaneous sumatriptan in head-to-head trials.10-12 Each of these medications has demonstrated superiority to placebo. Hyperkinetic motor side effects, such as akathisia or abrupt onset restlessness, are common but can be prevented with anticholinergics such as diphenhydramine. Irreversible motor disturbances after one dose of these medications have never been reported and fear of this occurrence should not dissuade the EP from their use.
Occipital Nerve Block
Regional nerve blocks may be effective for some patients. Performing a greater occipital block using a combination of a long-acting local anesthetic and a corticosteroid may provide rapid and lasting relief for some migraineurs. This strategy has many proponents, though data supporting or refuting its efficacy do not exist.13
Opioids
Opioids are the class of medication used most commonly to treat migraine in US and Canadian EDs.14,15 Though highly effective for acute pain, opioids are less desirable treatment for acute migraine for the following reasons: (1) Opioids are less effective than other treatment regimens such as the antiemetic dopamine antagonists and dihydroergotamine combinations; (2) they are associated with an increased number of repeat ED visits; (3) it is difficult to send patients back to work or allow them to drive home after treatment with an opioid; and (4) opioids are associated with worsening of the underlying migraine disorder. In outpatient studies, opioids were thought to cause transformation of episodic migraine into chronic daily headaches.17
Therefore, based on the above concerns, a patient who presents with a migraine to an ED for the first time should never be administered opioids unless contraindications or lack of response to other medications leave no alternative. A patient presenting frequently and insisting on opioid treatment represents a difficult patient population—one that is often characterized by psychiatric comorbidities and concomitant medication-overuse headache. Ideally, these patients are managed not during a busy shift but by a “difficult patient” committee that can create an appropriate interdisciplinary treatment plan for the patient and enforce that plan with a patient contract.
Other Treatment Options
For patients refractory to the treatments listed above, other options with potential benefit include propofol, haloperidol, valproic acid, and magnesium—the latter being particularly effective in treating migraine with aura.
Postdischarge Treatment
Regardless of the type of treatment, most patients who present to an ED with acute migraine have a recurrence of pain within 48 hours, thus requiring outpatient therapy.18 Parenteral or oral corticosteroids decrease the frequency of headache recurrence, though the optimal dose and route of administration is not known.19 Oral naproxen sodium, sumatriptan, or a combination of both (eg, combination oral tablet or a triptan taken along with naproxen sodium) are comparably effective in treating headache recurrence postdischarge. Because the two medications performed equally well in treating headache recurrence, physicians can choose between the two based on issues related to medication contraindications, cost, and patient preference.20
