Introduction
Headaches are a common presenting complaint in emergency medicine, yet they can signal a range of conditions from benign tension-type headaches to life-threatening intracranial pathology. For junior doctors navigating this clinical terrain, a systematic approach to history taking, investigation, and management is crucial. In this blog post, we'll break down the essentials of assessing and managing headaches in the emergency department, providing practical tips and guidelines based on the latest evidence and best practices.
History Taking: Key Questions to Ask
Effective history taking is the cornerstone of diagnosing headaches. Here’s a structured approach to ensure you gather all relevant information:
Onset and Duration:
When did the headache start?
Was it sudden or gradual?
Is this the first occurrence or has it happened before?
Location and Quality:
Where is the pain located? (e.g., frontal, temporal, occipital)
How would you describe the pain? (e.g., throbbing, sharp, dull)
Severity and Duration:
On a scale of 1 to 10, how severe is the headache?
How long does it last?
Associated Symptoms:
Are there any accompanying symptoms such as nausea, vomiting, visual disturbances, or neurological deficits?
Have you experienced any changes in consciousness or alertness?
Triggers and Relievers:
Have you noticed any specific triggers? (e.g., stress, certain foods, lack of sleep)
What, if anything, seems to relieve the pain?
Medical History:
Do you have a history of migraines, tension-type headaches, or cluster headaches?
Are there any recent head injuries or significant life changes?
Medication and Allergies:
What medications are you currently taking?
Are you allergic to any medications?
Red Flags:
Have you experienced a “thunderclap” headache or sudden severe headache?
Any recent change in your headache pattern or intensity?
Investigations: What to Consider
The choice of investigation largely depends on the clinical presentation and red flags identified during history taking. Here’s a guideline on what to consider:
Clinical Examination:
Perform a thorough neurological examination.
Check for signs of focal neurological deficits.
Imaging:
CT scan: Essential for ruling out acute intracranial pathology like hemorrhage, especially if there are red flags or sudden onset.
Lumbar Puncture:
Consider if there’s suspicion of meningitis, subarachnoid hemorrhage, or idiopathic intracranial hypertension.
Laboratory Tests:
Blood tests may be warranted to assess for infections, inflammatory conditions, or metabolic issues if clinically indicated.
Management Plan: Treating Headaches Effectively
Management strategies should be tailored based on the underlying diagnosis. Here’s a general approach:
Pain Relief:
Non-Opioid Analgesics: NSAIDs (e.g., ibuprofen) or acetaminophen for tension-type or mild migraines.
Triptans: For moderate to severe migraines.
Specific Treatments:
Migraine: Consider triptans or antiemetic for nausea.
Cluster Headaches: High-flow oxygen or triptans may be effective.
Acute Management:
If an acute secondary cause is identified (e.g., meningitis, intracranial hemorrhage), initiate appropriate treatment urgently (e.g., antibiotics, surgical intervention).
Discharge Planning:
Provide advice on follow-up care and signs of worsening conditions.
Discuss headache management strategies and refer to neurology or primary care if needed.
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