How I’ve waited this long to type about headaches is unclear. This is another in the category called “probably gonna be fine… could be deadly.”

My perspective on headaches was shaped more by one patient in 2001 than any other. I was a new attending, and an intern told me about a patient sitting in the noisy hallway with his family. The patient had a headache and thought it may have been from welding. I went to see him and he really didn’t seem too uncomfortable. He certainly wasn’t the picture of headache misery. That picture often includes sunglasses, a dark room, and a tearful, moaning patient curled up in the fetal position. This patient was sitting up and just squinting a bit. I really don’t like ordering excessive imaging, but because his family said he’d been a bit confused, I asked the intern to order a head CT. We both thought it was a reach.

About an hour later the wide-eyed intern with CT results found me saying the patient had a subarachnoid hemorrhage, or a bleed in his brain. A couple hours later he was in the OR having neurosurgery. My intern and I were fairly shocked. I hate to admit this, but the experience made me question my entire physical exam for such patients from that point on. This guy was normal and only a little bit of history triggered the scan. At least for headaches, I’m convinced now that history is the show.

Red Flags:

• Sudden onset
• Confusion
• “Worst headache of my life” (unless that was said 5, 10 and 15 days ago with normal CT, MRI and spinal taps)
• Fever
• Neck stiffness
• Ataxia (staggering, unsteady walking)
• Taking warfarin or other blood thinners
• Recent high impact head injury
• Syncope
• Seizure
• One sided weakness
• Unconscious (of course)
• Cancer
• No previous headaches
• Family history of aneurysms
• New pupil asymmetry

Happy Words

• “I have chronic migraines and just need some saline and Toradol.”
• “I ran out of my Norcos.”
• “I missed my morning Starbucks.”
• “I have an exam tomorrow and I’m very stressed.”
• “Everyone at home is sick and I’ve been sniffling all night.”
• “Normal MRI last week.”
• “I couldn’t get in to see my pain management doctor.”
• “I always get headaches with my periods.”
• “I need a work note.”

In the emergency department our first goal is to pluck out the life threats. Fine tuning after that is icing on the cake. When we hear “headache” we think of bleeding into the brain and infection. Rarely we are surprised by tumors, cysts, or other unusual lesions. While MRIs give much more information, they just aren’t rapidly available and they certainly aren’t comfortable. So if you have enough red flags, your next stop may be the CT scanner. Radiation is the downside, but for rapidly detecting life threatening bleeding, a head CT is excellent. If your headache persists, a lumbar puncture (spinal tap) could be next in search of bleeding or infection, but these are infrequent. Blood tests are virtually worthless to us in the ER in our search for the cause.

While chasing a diagnosis, in parallel we usually try to knock down the pain with a variety of medications, sometimes saline, and generally a dark room. However, unlike treatments for wheezing or allergic reactions, which are fairly consistent between doctors, the range of medication choices and approaches for patients with headaches is much more variable.

For me, I try to let patients drive as much as possible within reason. If I think there could be bleeding, then I avoid medications like Toradol or Aspirin before results of a CT. I try to steer patients away from narcotics as well to limit their side effects and addiction potential. On occasion I’ll try to inject a region behind the neck with local anesthetic which sometimes helps. Otherwise, I follow patient lead.

Those with chronic headaches generally know what works best for them. Regardless of medication choice, the hope is that after an hour or two of treatment and rest, they will soon be back on their feet and requesting to rest at home.

As for the naming of headaches, here’s a true confession… I still struggle. Migraine vs tension vs cluster vs anything else, it just isn’t an easy diagnosis to make, and there is plenty of gray in between. More important is finding solutions that work and that keep recurrent headaches under control.

My impression is that most people who suffer from chronic headaches spend a long time with over the counter medications like acetaminophen, ibuprofen naprosyn, Excedrin first. Once they’ve exhausted these, some then dabble with the medications of their relatives to see what may work.

Phenergan works for some while Imitrex works for others. Birth control pills can be life changing for women with monthly debilitating headaches. Sometimes a simple Starbucks coffee does the trick for caffeine hounds. Those at the ends of their ropes often move on to narcotics like Norco, Percocet, morphine, Dilaudid. But unfortunately, tolerance can build rapidly and withdrawal can be sheer agony. Sadly, patients with chronic headaches begging for Dilaudid injections are fairly commonplace nowadays.

I’ve had close friends who cycle through ERs with headaches, and it’s a real struggle… and expensive! Happily, some have found solutions. Topamax, seems like a popular migraine suppressant used by many.

Perhaps most important of all is to find a PCP, and possibly a neurologist or pain management specialist. If you call Pre-R with a headache, we may be able to help in a pinch. But realize you will have to speak mainly happy words. With even one or two red flags, I’m sorry we’ll be inclined to point you towards an ER. Until I develop X-ray vision, I suspect patients with headaches will forever make me nervous.

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