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C3 - Headache

Mel Herbert, MD MBBS FAAEM and Stuart Swadron, MD, FRCPC

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Tags C3 · Neurology
C3 - January 2016 Headache Written Summary 252 KB - PDF

A unique approach to the patient with headache with an emphasis on “Red Flag” symptoms and signs



Stuart Swadron, MD and Mel Herbert, MD

Take Home Points

  • The work up of headache is geared toward identifying primary vs secondary causes of the headache.

  • Consider Giant Cell Arteritis in older patients with headache

  • Consider cervical dissection in younger patients with headache.  

Your chart needs to reflect that you have thought about and evaluated for the red flags.

The Red Flags:

  • New onset

  • Neurological findings

  • Sudden Onset or worst at onset

  • Fever or immune compromise

  • Old person

  • Progressive headache

  • Jaw claudication, muscle aches, temporal artery pain

  • Multiple patients with headache (CO toxicity)

  • Think Drug Withdrawal

  • Pregnancy or post pregnancy

  • Clotting disorder

  • Trauma

  • Eye pain

  • Cervical Manipulation with facial pain or headache

  • Dizziness with headache

We are talking about the walking and talking patient with a headache.  Not a patient with a headache and systolic BP of 250.   

TREAT PAIN FIRST.  You can get a better, faster history from a patient whose pain has been managed.  There are 4-5 categories of drugs.  Tailor the treatment to the patient.  Ask what they took before they arrived and give them something different.  

  • NSAIDS and Acetaminophen.  Give PO, turn the lights off and reassess in a few minutes.  The faster the drug gets into the brain, the more effective it tends to be against headaches.  Effervescent aspirin, like Alka-Seltzer can be more effective than tablets.  

  • Dopamine antagonists.  Prochlorperazine (Compazine), metoclopramide (Reglan), chlorpromazine (Thorazine) are 80-90% effective at resolving headaches when given IV.  When given IM they are about 60-80% effective.  PO administration significantly decreases effectiveness to the placebo range of 40%.  

    • The most important side effect is QT prolongation.  

  • Abortive medications.  Sumatriptan (Imitrex) is most effective in the early stage or during the aura of the headache.  

  • Opioids.  It is acceptable to give opioids after you have tried other meds without success.  However, they are not as effective as the dopamine antagonists and set patients up for dependence.  

FOCUSED HISTORY SECOND.  Once the headache is under control, do a good history and physical.  Response to analgesia is not a diagnostic test; dangerous headaches can respond well to Tylenol.  

  • The evaluation of headache revolves around the issue of primary vs secondary causes of headache.

  • A history of recurrence and a history of therapy in the past is very important.  It guides your work up and your therapy.

Primary Headaches

  • Tension headaches are the most common type of headache.  Most frequently seen in men, are bilateral, and usually have a cause that can be identified in the patient’s life like sleep schedule, stress, depression, etc.  

  • Migraine headaches classically feature an aura (a warning sensation that the headache is about to come on), visual sensations like scintillations (colored lights) or holes in the vision (scotomas), photophobia and phonophobia.  In the UC, it is not important to determine the difference between a migraine and a different type of chronic, recurrent headache.

    • Migraine headaches are known to cause neurologic deficits or autonomic features.  However, if it looks like a stroke, treat it like a stroke and transfer to the ED.  The only exception is if the patient presents with a very clear history of migraine headaches with a neurologic deficit that is well established, unchanged from previous, and is resolved or getting better

    • A hard neurologic finding is any finding that could be explained by a specific lesion in the brain.  A sense of confusion, lightness, or trouble focusing are not hard neurologic findings.  Inability to move a part of the body, cranial nerve deficit or ataxia are hard neurologic findings.  In general, these symptoms are not benign require transfer to an ED

  • Cluster headaches are seen in men and they occur several times over the course of days or weeks.  The headaches are intense, usually centered behind one eye, and are often so bad the patients cannot keep still.  They may have neurologic findings like a myosis or a ptosis, lacrimation or facial sweating..  These may resolve with treatment (oxygen at high concentration, intranasal lidocaine administered to the ipsilateral nares), but hard neurologic findings need to be treated like a stroke until proven otherwise.  

  • Medication overuse syndromes are the 3rd most common cause of headaches.  Patients may have headaches because they are on medication for headaches.  These types of headaches are very common with opioid medications, and are also seen with caffeine, barbiturates, and OTC medications.  

Secondary Headache

  • Any headache that is new in onset is concerning for a secondary cause.

  • Red flags for secondary headache:

    • New onset headache.

    • Hard neurologic findings.

    • Sudden onset.

    • Maximal at onset (over 1-2 minutes).

    • Fever + headache—this is a difficult red flag because it is common and can be benign.

      • Consider a fever with a headache a concerning red flag if patients are immunocompromised (HIV, chronic steroids, alcoholics, homeless, partially treated with antibiotics) because these patients are more are more likely to have a meningitis.  

      • Over the past several years, meningitis has changed from being a pediatric disease to an adult disease.  Adults at higher risk are prisoners, military recruits and those living in college dormitories.  

      • If an immune-compromised treat for meningitis

        • Who does well with steroids?  There is evidence that 10mg of dexamethasone (Decadron) given before antibiotics can improve outcomes.  If your suspicion isn’t high, or if the patient is immunocompromised, the evidence is not clear so it is probably best to give the ceftriaxone without the dexamethasone.  

        • Who becomes hypotensive? Bacteremic patients can become hypotensive after administration of antibiotics as the bacteria lyse.  The treatment of this hypotension is fluid resuscitation, so make sure every patient has good IV access before giving antibiotics.  

Consider Giant Cell Arteritis (formerly called Temporal Arteritis) in every elderly patient with a headache.  

  • Symptoms include painful, enlarged temples and jaw claudication.  

  • Start steroids empirically with 60-80mg prednisone PO because early administration is critical to saving the patient’s vision and does not change the results of the biopsy.   

  • If you are concerned about GCA in a patient who does not have the classic features, send an ESR.  If the ESR is low, it is unlikely to be GCA.  If the ESR is high without another explanation, start steroids and refer them to Ophthalmology for biopsy.  If your lab takes a long time to process the ESR, send it anyway but add a CRP.  

Consider cervical dissection as it is a significant cause of stroke in young people (30s).  Like SAH, cervical dissections present with a sudden onset of headache and patients often report significant facial pain in addition to the headache.  The majority are caused by low mechanism trauma like yoga or dancing with the sudden onset of lancinating pain radiating up either the back or the front of the neck.  These patients need to go to the ED for either CT or MR angiogram.  Treatment is usually heparin.  

James M., MD -

Did you mean eclampsia as a cause of postpartum headache or preeclampsia or both. I believe you said preeclampsia which confused me a little.

Paul -


Rabbott -

Hey, guys - I once heard that there used to be a disease called "Pseudotumor Cerebri" - undoubtedly has a new terminology in ICD 10. Doesn't that cause headaches? And, shouldn't we consider that in the - usually young - person with ongoing, daily, unremitting headache - perhaps who has been thrown out of several other ER's because of return visits (true story). I'd argue that ongoing, relatively longstanding headaches should all have an LP if the CT is negative (yes, a funduscopic exam may be diagnostic but we can't do those in the new age of high efficiency medicine, God forbid if a resident takes time to do a funduscopic exam or ocular ultrasound). Although high csf pressure is the most frequent diagnostic finding, you periodically stumble into the chronic meningitis, such as TB. And, then there is the other extreme of intracranial hypotension - I suspect that an LP, with pressure measurement, is a good idea in all headaches that are relieved by lying down. (For reasons that escape me, I made this diagnosis as many times in my 4 months in Tasmania as in the other 45 years of my career).

Greggae -

As a relatively newly-graduated resident I had the fundoscopic exam/ technique drilled into me I am happy to say.

Cristina L. -

I'm loving C3 project. Please submit more of these!

Angelika U. -

What a great review of headaches! thank you so much

John M., M.D. -


Jessica H. -

thanks so much for starting the C3 back up again, please keep them going!

django -

I once heard you could still have a normal ESR and wind up having a positive biopsy for Temporal arteritis. I suppose if your suspicion is high you would still start them on steroids.

Brian B. -

Is there a written summary of the C3's that I am missing?

Brian B. -

I was looking in the area where you put summaries for the other episodes and missed the big "Summary" tab initially. It does not appear downloadable however, can you put this into a pdf and allow downloads for paid subscribers?

Mel H. -

It is downloadable - under the download tabs there is a PDF.

Erin M. -

LOVE the information I'm getting here! However, I noticed that the written summary seems to stop after GC Arteritis and doesn't cover the rest of the podcast. Will the summary be updated to include everything from pregnancy to the end?

Sharmin K. -

Another DDX for headache, I consider in back of my head is cavernous sinus thrombosis, outside of pregnancy. I consider it more on anyone with hypercoagulable disorder, CN 3-6 deficit. I have not seen a case myself but wanted your wisdom on existing cases and how to augment my clinical suspicion. Is CT head venogram sufficient to rule it out or MRI must be done for moderate to high suspicion?

Roderick F. -

In cases where there is high suspicion (i. e. postpartum female with altered mental status) a CTV is sufficient.

Adam N. PA-C MS -

What's your guys thougts on CT head being negative within first few hours of headache suspicious for SAH ? Sensitivity for SAH is very high in first few hours ( I wanna say 95+%). Are LPs still standard practice even with neg head CT within first few hours of symptom onset? So basically, If I have a patient with red flag SAH symptoms starting 3 hours ago and CT head negative am I still telling this patient " Hey, I still have to stick this long needle into your spinal column"?

Adam N. PA-C MS -

I just listened to the January short on this subject so question answered. Thanks!

RAM D., Dr -

Thank you Dr Mel & Stewart.
Great C3 which is real.

Sharon M., Dr. -

I will never forget a recent brain abscess I missed in a mid 20s male presenting mid winter 'flu like symptoms and frontal headache, along w a high percentage of pts that same shift. Next morning, lethargic unable to walk, ambulance to hospital - workup revealed a brain abscess. Seized for 45mins in hospital, L hemiplegia....still in ICU.
Brain abscess will always be on my differential, but I still fail to see how I could prevent missing another similar initial presentation - so general and common the initial presentation! Headache and 'flu like symptoms.

Brad L. -

What about syncope related to headache as a red flag???

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C3 - Headache Full episode audio for MD edition 36:47 min - 32 MB - M4AC3 - Headache - MP3 51 MB - MP3C3 - January 2016 Headache Written Summary 252 KB - PDF