LOS ANGELES—One of the more difficult times to treat a headache patient is when he or she has an acute, severe headache that requires the personal attention of a neurologist in the office or the emergency department, according to Alan M. Rapoport, MD, Director of the New England Center for Headache in Stamford, Connecticut. "These patients usually look like they are severely ill neurologically; they’re in a lot of pain, and physicians have to make fairly quick decisions about what to do—which are fraught with some danger because the patients could be harboring a much more serious process than the usual disabling migraine attack."

To help physicians interested in headache address these issues, Dr. Rapoport and R. Allan Purdy, MD, organized and cochaired a symposium on the emergency care of headache at the 48th Annual Scientific Meeting of the American Headache Society. Topics ranged from examination and diagnosis in the emergency department to phone consultations and follow-up.

"The topic of headache in the emergency department is relevant for all physicians who care for patients with headache, because they have the ability to help their patients avoid emergency department visits," said Dr. Rapoport, presenting on behalf of Jonathan Gladstone, MD, of the Gladstone Headache Clinic in Toronto. He cited clinical studies demonstrating that implementation of certain acute and preventive treatment strategies can decrease emergency department visits by up to 85%. "Clinicians should routinely inquire about their patients’ use of the emergency department for headache relief and seek to implement appropriate treatment strategies to limit their patients’ reliance on the emergency department."

"For the migraineur, the last place [he or she] wants to be is in a crowded, loud, bright, cold, noisy, chaotic emergency department," he said. "[As] for the emergency department physicians and administrators, they are usually less than thrilled to have a migraineur taking up an emergency department bed until his or her headache subsides."

Once migraine patients are admitted, they are often misdiagnosed—typically with a benign headache or headache not otherwise specified (NOS). This happens due to practical reasons as well as the trend toward practicing defensive medicine. "Rather than committing themselves to a specific diagnosis of migraine, many emergency department physicians prefer to leave the door wide open by diagnosing patients with headache NOS," Dr. Rapoport said. "Obviously, in certain circumstances this is a defensive strategy to avoid potential medical-legal issues down the road. Equally likely, the physicians simply do not have the time to take a detailed longitudinal headache history to ascertain a previous history of migraine, nor do they have the time to tease out a diagnosis of migraine for the particular headache in question.

IN THE ABSENCE OF A STANDARD OF CARE

With more than 35 different drugs for headache utilized in the emergency department, the choices can be overwhelming. "It would be advisable for all physicians caring for migraine patients in the emergency department to develop a comfort level with dihydroergotamine, at least one or two dopamine antagonists, an antiemetic, [and] a parenteral NSAID, as well as one parenteral opioid," Dr. Rapoport observed. "Based on the patient’s comorbidities and contraindications, medications can be selected from this list accordingly, with parenteral opioids reserved for rescue therapy."

THE TROUBLE WITH TRIPTANS

"Certainly there is room for improvement when it comes to providing patients with treatment strategies for acute migraines, as well as providing patients with rescue strategies to minimize emergency department presentation when their acute migraine management strategies fail," Dr. Rapoport said.

He pointed to several reasons why triptans are not used more often in the emergency department. "Up to 20% of migraineurs may have tried a triptan prior to coming to the emergency department, and there are limits on the amount of triptans that can be prescribed within 24 hours; and two different triptans cannot be used within the same 24 hours," he observed.

"Secondly, by the time many migraine patients arrive in the emergency department, their headaches have been ongoing for a prolonged period, have reached a severe intensity level, and nausea and vomiting may be ongoing. In this situation, triptans may not be efficacious enough for some patients to abort the attack.

A final step that can reduce the likelihood that headache patients will return to the emergency department is appropriate discharge. It is critical that patients be referred to a local headache specialist or a neurologist with an interest in headache, Dr. Rapoport maintained. "Clinical studies have demonstrated that consultation with a neurologist/ headache specialist and implementation of appropriate acute and preventive treatment strategies can significantly decrease emergency department visits for headache in the year following consultation and initiation of migraine-specific treatment," he concluded.

ASSUME THE WORST

A good rule of thumb for neurologists consulting in the emergency department is to always assume the worst, said R. Allan Purdy, MD, Professor and Head of the Departments of Medicine and Neurology at Dalhousie University Medical School in Halifax, Nova Scotia. "In headache, everything is history, because it is a subjective symptom," he said. "Primary headaches are common, much more common than secondary ones in the general population—it’d be about 90 to 10. But in an emergency department … [headaches] might be skewed slightly toward the more serious because [individuals] go to the emergency department thinking this severe attack is different from their usual headache. Often, patients come into the emergency department saying this headache wasn’t like their migraine before, but it had changed from a previous pattern … or [was] the worst headache they ever had."

Such clues from the history should inform the physical examination because secondary headache should always be a "primary" consideration, in Dr. Purdy’s view. Differentiating primary from secondary headaches is confounded by the fact that they share an identical anatomy, rendering imaging tests of limited value in distinguishing between the two types.

"One of the problems with headache in the emergency department is premature conclusions preclude subsequent thought," Dr. Purdy continued. "If you get into an emergency setting and you have a patient with a headache, you have to keep an extremely open mind to the differential diagnosis, because a lot of patients have secondary headaches that can masquerade as primary headaches. Sometimes examination findings are subtle, and frequently the findings on imaging can be difficult to interpret."

WATCH OUT FOR RED FLAGS

"The most important thing is to remember to do the fundamentals. That’s the single most common mistake we see, where [neurologists] get called and they don’t approach the problem with an open mind," Dr. Ward said. "For example, if somebody has a history of migraine headache, the default is ‘Well, it’s another migraine,’ and that’s usually true. But it’s not always true, so you have to have a fresh approach every time you see a patient, to make sure it’s not a different headache that the patient is having, [despite the] history of migraine.

"The other thing that I like to stress is that if in fact the patient is having migraine, I work very hard with my patients to have a plan so that they don’t end up in the emergency department in the first place."

Working from the history and physical examination, clinicians should choose tests depending on the timing involved and what tests are available at that institution. If an underlying cause is suspected, tests should be chosen to confirm or refute the possible diagnosis. Emergency department personnel should not hesitate to consult within or outside of the institution or to transfer the patient if tests deemed necessary are not available.

Sometimes a patient’s presentation will raise "red flags," and the clinician may have to trust his or her own instincts in interpreting the signs. "Red flags are things that ought to raise your index of suspicion that maybe you’re dealing with a secondary headache, or something is not quite right with the story that should make you think a little harder and look a little bit harder," Dr. Ward said, recounting a case he saw almost 20 years ago:

A 56-year-old woman with a history of hypertension and a long history of migraine presented to the emergency department, insistent that something was wrong even though her condition was not "very impressive." Her typical headache had a gradual onset with nausea but no vomiting and was usually relieved when she lay down in a dark, quiet room and went to sleep. On the day of presentation, she developed her usual headache, except she vomited once, which relieved the headache. Her vital signs, lab results, and general and neurologic exams were all normal. Because of the slightly different presentation this time, Dr. Ward admitted the patient for observation and kept her overnight.

In other cases, the hemorrhage might have posed a serious problem. "Had it been a truly serious or worrisome problem, I would have expected her presentation to have been more dramatic," he said. "As was pointed out to me, the one thing was she had this change in the pattern of her headache that was the red flag. So I kept an open mind, brought her into the hospital and kept an eye on her, and she did change."

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