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Acute headache management in emergency department. A narrative review


Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. Most frequent primary forms motivating ED observation are acute migraine attacks, particularly status migrainous, and cluster headache. Though universally accepted guidelines do not exist for headache management in an emergency setting, pharmacological parenteral treatment remains the principal approach worldwide, with NSAIDs, neuroleptic antinauseants, triptans and corticosteroids, tailored to the specific headache type. Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.

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  1. 1.

    Lucado J, Paez K, Elixhauser A (2011) Headaches in U.S. Hospitals and emergency departments, 2008. HCUP statistical brief #111. Rockville, MD: Agency for Healthcare Research and Quality.

  2. 2.

    Barleycorn D (2016) Systematic review: Is Metoclopramide more effective than Sumatriptan in relieving pain from migraine in adults in the emergency department (ED) setting? Int Emerg Nurs 27:51–55

    PubMed  Google Scholar 

  3. 3.

    Cortelli P, Aguggia M (2017) La cefalea in Pronto Soccorso, Emergency Care Journal. Organizzazione, clinica, ricerca • Anno III numero IV.

  4. 4.

    Zodda D, Procopio G, Gupta A (2019) Evaluation and management of life-threatening headaches in the emergency department. Emerg Med Pract 21(2):1–20

    PubMed  Google Scholar 

  5. 5.

    Chinthapalli K, Logan AM, Raj R, Nirmalananthan N (2018) Assessment of acute headache in adults—What the general physician needs to know. Clin Med (Lond) 18(5):422–427

    Google Scholar 

  6. 6.

    Munoz-Ceron J, Marin-Careaga V, Peña L, Mutis J, Ortiz G (2019) Headache at the emergency room: Etiologies, diagnostic usefulness of the ICHD 3 criteria, red and green flags. PLoS ONE 14(1):e0208728

    CAS  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Filler L, Akhter M, Nimlos P (2019) Evaluation and Management of the emergency department headache. Semin Neurol 39(1):20–26

    PubMed  Google Scholar 

  8. 8.

    Walling A (2018) Headache: headache emergencies. FP Essent 473:21–25

    PubMed  Google Scholar 

  9. 9.

    Headache Classification Committee of the International Headache Society (IHS) (2018) the international classification of headache disorders, 3rd edition. Cephalalgia 38(1):1–211.

  10. 10.

    Jesani J, Simerson D (2019) Pharmacologic management of acute migraines in the emergency department. Adv Emerg Nurs J 41(2):150–162

    PubMed  Google Scholar 

  11. 11.

    Goldstein JN, Camargo CA Jr, Pelletier AJ, Edlow JA (2006) Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia 26:684–690

    CAS  PubMed  Google Scholar 

  12. 12.

    Giamberardino MA, Vecchiet L (1995) Visceral pain, referred hyperalgesia and outcome: new concepts. Eur J Anaesthesiol Suppl 10:61–66

    CAS  PubMed  Google Scholar 

  13. 13.

    Giamberardino MA, Affaitati G, Costantini R (2006) Chapter 24 Referred pain from internal organs. Handb Clin Neurol 81:343–361

    PubMed  Google Scholar 

  14. 14.

    Giamberardino MA, Affaitati G, Costantini R (2010) Visceral referred pain. J Musculoske Pain 18:403–410

    Google Scholar 

  15. 15.

    Giamberardino MA, Tana C, Costantini R (2014) Pain thresholds in women with chronic pelvic pain. Curr Opin Obstet Gynecol 26:253–259

    PubMed  Google Scholar 

  16. 16.

    Tana C, Tafuri E, Tana M, Martelletti P, Negro A, Affaitati G, Fabrizio A, Costantini R, Mezzetti A, Giamberardino MA (2013) New insights into the cardiovascular risk of migraine and the role of white matter hyperintensities: is gold all that glitters? J Headache Pain 14:9

    PubMed  PubMed Central  Google Scholar 

  17. 17.

    Tana C, Santilli F, Martelletti P, di Vincenzo A, Cipollone F, Davì G, Giamberardino MA (2015) Correlation between migraine severity and cholesterol levels. Pain Pract 15:662–670

    PubMed  Google Scholar 

  18. 18.

    Giamberardino MA, Tafuri E, Savini A, Fabrizio A, Affaitati G, Lerza R, Di Ianni L, Lapenna D, Mezzetti A (2007) Contribution of myofascial trigger points to migraine symptoms. J Pain 8:869–878

    PubMed  Google Scholar 

  19. 19.

    Giamberardino MA, Affaitati G, Fabrizio A, Costantini R (2011) Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol 25:185–198

    PubMed  Google Scholar 

  20. 20.

    Heetderks-Fong E (2014) Appropriateness criteria for neuroimaging of adult headache patients in the emergency department: How are we doing? Adv Emerg Nurs J 41(2):172–182

    Google Scholar 

  21. 21.

    Alons IM, van den Wijngaard IR, Verheul RJ, Lycklama À, Nijeholt G, Wermer MJ, Algra A, Jellema K (2015) The value of CT angiography in patients with acute severe headache. Acta Neurol Scand 131:164–168

    CAS  PubMed  Google Scholar 

  22. 22.

    Gill HS, Marcolini EG, Barber D, Wira CR (2018) The utility of lumbar puncture after a negative head CT in the emergency department evaluation of subarachnoid hemorrhage. Yale J Biol Med 28;91(1):3–11.

  23. 23.

    Steffens S, Tucker P, Evans DD (2018) Acute Headache in the emergency department: is lumbar puncture still necessary to rule out subarachnoid hemorrhage? Adv Emerg Nurs J 40(2):78–86

    PubMed  Google Scholar 

  24. 24.

    Long D, Koyfman A, Long B (2019) The Thunderclap headache: approach and management in the emergency department. J Emerg Med 56(6):633–641

    PubMed  Google Scholar 

  25. 25.

    Malhotra A, Wu X, Gandhi D, Sanelli P (2018) The patient with thunderclap headache. Neuroimaging Clin N Am 28(3):335–351

    PubMed  Google Scholar 

  26. 26.

    Gallerini S, Marsili L, Bartalucci M, Marotti C, Chiti A, Marconi R (2019) Headache secondary to cervical artery dissections: practice pointers. Neurol Sci 40(3):613–615

    PubMed  Google Scholar 

  27. 27.

    Tana C, Caulo M, Tafuri E, Di Vincenzo A, Tana M, De Angelis MV, Mezzetti A (2014) Giamberardino MA (2014) Teaching neuroimages: a dangerous complication of spontaneous intracranial hypotension. Neurology. 82(11):e94–e95

    PubMed  Google Scholar 

  28. 28.

    Mayele MOF, Bertrand X (2018) Subarachnoid hemorrhage resulting from a ruptured aneurysm: management in an emergency department. Rev Med Liege 73(5–6):344–350

    PubMed  Google Scholar 

  29. 29.

    Marcolini E, Hine J (2019) Approach to the diagnosis and management of subarachnoid hemorrhage. West J Emerg Med 20(2):203–211

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Hohl CM, Sutherland J, Émond M, Worster A, Lee JS, Mackey D, Pauls M, Lesiuk H, Symington C, Wells GA (2013) Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 310(12):1248–1255

    CAS  PubMed  Google Scholar 

  31. 31.

    Probst MA, Hoffman JR (2016) Computed tomography angiography of the head is a reasonable next test after a negative noncontrast head computed tomography result in the emergency department evaluation of subarachnoid hemorrhage. Ann Emerg Med 67(6):773–774

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Dorsett M, Liang SY (2016) Diagnosis and treatment of central nervous system infections in the emergency department. Emerg Med Clin North Am 34(4):917–942

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    Kim KJ, Cho JH, Moon JB, Shin MC, Ohk TG, Lee HY, Park CW (2017) What factors determine the need for lumbar puncture in patients with fever and headache? Singapore Med J 58(10):618–622

    PubMed  PubMed Central  Google Scholar 

  34. 34.

    Comelli I, Lippi G, Campana V, Servadei F, Cervellin G (2017) Clinical presentation and epidemiology of brain tumors firstly diagnosed in adults in the emergency department: a 10-year, single center retrospective study. Ann Transl Med 5(13):269

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z (2018) Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain. 21; 19(1):17

  36. 36.

    Martelletti P, Schwedt TJ, Lanteri-Minet M, Quintana R, Carboni V, Diener HC, Ruiz de la Torre E, Craven A, Rasmussen AV, Evans S, Laflamme AK, Fink R, Walsh D, Dumas P, Vo P (2018) My Migraine Voice survey: a global study of disease burden among individuals with migraine for whom preventive treatments have failed. J Headache Pain 19(1):115

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Sahai-Srivastava S, Desai P, Zheng L (2008) Analysis of headache management in a busy emergency room in the United States. Headache 48:931–938

    PubMed  Google Scholar 

  38. 38.

    Levin M (2015) Approach to the workup and management of headache in the emergency department and inpatient settings. Semin Neurol 35:667–674

    PubMed  Google Scholar 

  39. 39.

    Naeem F, Schramm C, Friedman BW (2018) Emergent management of primary headache: a review of current literature. Curr Opin Neurol 31:286–290

    PubMed  Google Scholar 

  40. 40.

    Cameron JD, Lane PL, Speechley M (1995) Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine headache. Acad Emerg Med 2:597–602

    CAS  PubMed  Google Scholar 

  41. 41.

    Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT (2010) A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med 56:1–6

    PubMed  Google Scholar 

  42. 42.

    Kelley NE, Tepper DE (2012) Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others. Headache 52:292–306

    PubMed  Google Scholar 

  43. 43.

    Friedman BW, Garber L, Yoon A, Solorzano C, Wollowitz A, Esses D, Bijur PE, Gallagher EJ (2014) Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology 82:976–983

    CAS  PubMed  Google Scholar 

  44. 44.

    Najjar M, Hall T, Estupinan B (2017) Metoclopramide for acute migraine treatment in the emergency department: an effective alternative to opioids. Cureus 20; 9(4):e1181. doi: 10.7759/cureus.1181.

  45. 45.

    Bartolini M, Giamberardino MA, Lisotto C, Martelletti P, Moscato D, Panascia B, Savi L, Pini LA, Sances G, Santoro P, Zanchin G, Omboni S, Ferrari MD, Fierro B, Brighina FA (2011) Double-blind, randomized, multicenter, Italian study of frovatriptan versus almotriptan for the acute treatment of migraine. J Headache Pain 12:361–368

    CAS  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Subcutaneous Sumatriptan International Study Group (1991) Treatment of migraine attacks with sumatriptan. N Engl J Med 325:316–321

    Google Scholar 

  47. 47.

    Sumatriptan Cluster Headache Study Group (1991) Treatment of acute cluster headache with sumatriptan. N Engl J Med 325:322–326

    Google Scholar 

  48. 48.

    Shrestha M, Singh R, Moreden J, Hayes JE (1996) Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A prospective, randomized, double-blind trial. Arch Intern Med 156:1725–1728

    CAS  PubMed  Google Scholar 

  49. 49.

    Seim MB, March JA, Dunn KA (1998) Intravenous ketorolac vs intravenous prochlorperazine for the treatment of migraine headaches. Acad Emerg Med 5:573–576

    CAS  PubMed  Google Scholar 

  50. 50.

    Kelley NE, Tepper DE (2012) Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications. Headache 52:467–482

    PubMed  Google Scholar 

  51. 51.

    Taggart E, Doran S, Kokotillo A, Campbell S, Villa-Roel C, Rowe BH (2013) Ketorolac in the treatment of acute migraine: a systematic review. Headache 53:277–287

    PubMed  Google Scholar 

  52. 52.

    Gelfand AA, Goadsby PJ (2012) A Neurologist's guide to acute migraine therapy in the emergency room. Neurohospitalist 2:51–59

    PubMed  PubMed Central  Google Scholar 

  53. 53.

    Costantini R, De Nicola P, Bianco F, Cotroneo AR, Iezzi R, Di Bartolomeo N, Innocenti P (2007) Tumor vs non-tumor origin of occult and obscure gastrointestinal bleeding requiring hospitalization. Tumori 93:461–466

    PubMed  Google Scholar 

  54. 54.

    Affaitati G, Martelletti P, Lopopolo M, Tana C, Massimini F, Cipollone F, Lapenna D, Giamberardino MA, Costantini R (2017) Use of nonsteroidal anti-inflammatory drugs for symptomatic treatment of episodic headache. Pain Pract 17:392–401

    PubMed  Google Scholar 

  55. 55.

    Tornabene SV, Deutsch R, Davis DP, Chan TC, Vilke GM (2009) Evaluating the use and timing of opioids for the treatment of migraine headaches in the emergency department. J Emerg Med 36:333–337

    PubMed  Google Scholar 

  56. 56.

    Tepper SJ (2012) Opioids should not be used in migraine. Headache 52(Suppl. 01):30–34

    PubMed  Google Scholar 

  57. 57.

    McCarthy LH, Cowan RP (2015) Comparison of parenteral treatments of acute primary headache in a large academic emergency department cohort. Cephalalgia 35:807–815

    PubMed  Google Scholar 

  58. 58.

    Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH (2008) Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 336:1359–1361

    PubMed  PubMed Central  Google Scholar 

  59. 59.

    Vécsei L, Szok D, Nyári A, Tajti J (2018) Treating status migrainosus in the emergency setting: what is the best strategy? Expert Opin Pharmacother 19(14):1523–1531

    PubMed  Google Scholar 

  60. 60.

    Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett R, PalmaT De, Rosenthal B, Tepper S, Lipton RB (2010) Interventional procedures special interest section of the American. Peripheral nerve blocks and trigger point injections in headache management—a systematic review and suggestions for future research. Headache 50:943–952

    PubMed  Google Scholar 

  61. 61.

    Giamberardino MA, Dragani L, Valente R, Di Lisa F, Saggini R, Vecchiet L (1996) Effects of prolonged L-carnitine administration on delayed muscle pain and CK release after eccentric effort. Int J Sports Med 17(5):320–324

    CAS  PubMed  Google Scholar 

  62. 62.

    Reisenauer SJ (2012) A needle in the neck: trigger point injections as headache management in the emergency department. Adv Emerg Nurs 34:350–356

    Google Scholar 

  63. 63.

    Ducharme J (1999) Canadian Association of Emergency Physicians guidelines for the acute management of migraine headache. J Emerg Med 17:137–144

    CAS  PubMed  Google Scholar 

  64. 64.

    Gupta MX, Silberstein SD, Young WB, Hopkins M, Lopez BL, Samsa GP (2007) Less is not more: underutilization of headache medications in a university hospital emergency department. Headache 47:1125–1133

    PubMed  Google Scholar 

  65. 65.

    Pari E, Rinaldi F, Gipponi S, Venturelli E, Liberini P, Rao R, Padovani A (2015) Management of headache disorders in the Emergency Department setting. Neurol Sci 36:1153–1160

    PubMed  Google Scholar 

  66. 66.

    Giamberardino MA, Martelletti P (2015) Emerging drugs for migraine treatment. Expert Opin Emerg Drugs 20:137–147

    CAS  PubMed  Google Scholar 

  67. 67.

    Giamberardino MA, Mitsikostas DD, Martelletti P (2015) Update on medication-overuse headache and its treatment. Curr Treat Options Neurol 17:368

    PubMed  Google Scholar 

  68. 68.

    Giamberardino MA, Affaitati G, Curto M, Negro A, Costantini R, Martelletti P (2016) Anti-CGRP monoclonal antibodies in migraine: current perspectives. Intern Emerg Med 11:1045–1057

    PubMed  Google Scholar 

  69. 69.

    Giamberardino MA, Costantini R (2017) Challenging chronic migraine: targeting the CGRP receptor. Lancet Neurol 16:410–411

    PubMed  Google Scholar 

  70. 70.

    Giamberardino MA, Affaitati G, Costantini R, Cipollone F, Martelletti P (2017) Calcitonin gene-related peptide receptor as a novel target for the management of people with episodic migraine: current evidence and safety profile of erenumab. J Pain Res 10:2751–2760

    CAS  PubMed  PubMed Central  Google Scholar 

  71. 71.

    Martelletti P (2019) Erenumab is effective in reducing migraine frequency and improving physical functioning. BMJ Evid Based Med. 24(2):76

    PubMed  Google Scholar 

  72. 72.

    Tulla M, Tillgren T, Mattila K (2019) Is there a role for lumbar puncture in early detection of subarachnoid hemorrhage after negative head CT? Intern Emerg Med 14(3):451–457

    PubMed  Google Scholar 

  73. 73.

    Cox M, Sedora-Román NI, Pukenas B, Kung D, Robert Hurst R (2018) Reversible cerebral vasoconstriction syndrome: an important non-aneurysmal cause of thunderclap headaches and subarachnoid hemorrhage. Intern Emerg Med 13(1):135–136

    PubMed  Google Scholar 

  74. 74.

    Anticoli S, Bravi MC, Pezzella FR (2017) Reversible cerebral vasoconstriction syndrome after intercontinental airplane travel. Intern Emerg Med 12(8):1327–1328

    PubMed  Google Scholar 

  75. 75.

    Bedaso A, Geja E, Ayalew M, Oltaye Z, Duko B (2018) Post-concussion syndrome among patients experiencing head injury attending emergency department of hawassa university comprehensive specialized hospital, hawassa Southern Ethiopia. J Headache Pain 19(1):112

    PubMed  PubMed Central  Google Scholar 

  76. 76.

    Doretti A, Shestaritc I, Ungaro D, Lee J-I, Lymperopoulos L, Kokoti L, Guglielmetti M, Mitsikostas DD, Lampl C, School of Advanced Studies of the European Headache Federation (EHF-SAS) (2019) Headaches in the emergency department—a survey of patients' characteristics. Facts and Needs. J Headache Pain 20(1):100

    Google Scholar 

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Correspondence to Paolo Martelletti.

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Giamberardino, M.A., Affaitati, G., Costantini, R. et al. Acute headache management in emergency department. A narrative review. Intern Emerg Med 15, 109–117 (2020).

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  • Headache
  • Migraine
  • Emergency department
  • Secondary headache
  • Management
  • Drugs