Headache

What is Headache?

Headache, or pain in the head, is an extremely common issue. Headaches account for 3% of the reasons why people seek emergency medical attention. While the majority of headaches (96%) are harmless, it’s crucial to identify the infrequent, urgent causes of headaches because prompt treatment can indeed save lives. Emergency healthcare providers play a critical role in this process.

They have to carefully evaluate a patient’s medical history and perform physical examinations to figure out if the patient is at risk of any serious hidden conditions. They also have to decide which patients need immediate additional tests. These might include laboratory work and diagnostic imaging to confirm any diagnoses and guide treatment strategies.

Aside from diagnosing and treating life-threatening causes of headaches, emergency healthcare providers also need to effectively treat everyday headache disorders. By correctly managing the typical progression of these disorders, patient results can significantly improve.

What Causes Headache?

Headaches can generally be split into two types: primary and secondary. Primary headaches don’t have a clear cause. Secondary headaches are caused by some other health problem.

Experts categorize headaches as follows: Primary headaches, which include tension headaches, migraines, and cluster headaches. Secondary headaches, which can be caused by serious health issues like traumatic brain injuries and issues with blood vessels. Lastly, cranial neuropathies like trigeminal neuralgia, which is a specific nerve condition.

A headache can be a sign of a variety of health problems, some of which can be serious or even deadly. Medical emergency professionals should be familiar with conditions like:

* Dangerous levels of high blood pressure
* A condition where the pressure in the brain is too high for no clear reason
* Conditions where the arteries in the neck are torn or split
* The presence of objects in the brain-space (like tumors, abscesses, or cysts)
* A sudden overload of fluid in the brain
* A condition where a brain vein gets blocked by a blood clot
* Bleeding inside the skull
* A blood vessel disease that particularly affects the temples
* A stroke
* Brain infections
* Carbon monoxide poisoning
* Exposure to or withdrawal from toxins
* A specific type of glaucoma where the eye’s internal pressure rises quickly
* Overusing certain medications causing headaches

Risk Factors and Frequency for Headache

Headaches are often overlooked and not treated sufficiently by healthcare professionals, even though they have a significant impact on our wellbeing. Headaches most commonly affect young, healthy individuals, typically between the ages of 25 to 40. After that, their frequency decreases in both men and women. Almost everyone in the United States, around 96% of people, is likely to experience a headache at some point in their lives. Women are more likely to suffer from chronic active headaches than men. For example, severe headaches or migraines occur in 20.7% of women and 9.7% of men.

As of now, it’s unclear whether the number of people who have headaches varies by region. Differences in how data is collected across the world, the criteria for diagnosing headaches, and how different cultures understand and describe headaches can all affect the accuracy of the data.

Signs and Symptoms of Headache

Patients with headaches can often be diagnosed through a careful record of their symptoms and a physical examination. Primary headaches aren’t life-threatening and usually don’t need any emergency imaging or special tests. However, not all headaches are harmless; certain secondary headaches can signal underlying conditions which are more serious and must be identified before a primary headache diagnosis is given.

Health professionals will ask many questions about the patient’s current headache, their general health, and history of headaches. They will also ask specific questions that could identify any severe causes of their headache. These can influence further tests or urgent treatment.

The medical professional will usually ask these questions:

• Where is the pain located?
• When did the pain begin?
• What was the patient doing when the pain began?
• How has the pain changed?
• What kind of pain is it?
• How severe is the pain?
• Does anything make the pain better or worse?
• Does the pain spread to other areas?
• Has the patient experienced this kind of pain before?

Also, they will request information on the patient’s medical history, any new or altered medications, general symptoms like dizziness or weakness, and any recent travel or potential exposures to illness.

A physical examination is essential for diagnosing what’s causing the headache. The medical professional is also likely to perform a thorough HEENT (Head, Eye, Ear, Nose, Throat) examination, which can reveal signs of either harmless or more serious conditions.

The absence of certain features during the patient’s history and physical examination can suggest that the patient’s headaches are not caused by a serious underlying condition. If no red flags are present, the medical professional can focus on identifying if the headache is a primary type or due to a benign cause. However, if the patient’s answers show potential high-risk features, it may be necessary for them to have immediate neurological imaging.

Lower-risk features include:

• Under 50 years of age
• Typical features for primary headaches
• History of similar headache
• Normal neurologic exam
• No change in the usual headache pattern
• No high-risk health conditions
• No new or concerning findings on history or physical

The SNOOP mnemonic is useful for identifying warning signs for potentially dangerous underlying conditions:

• S: Systemic illness (fever, cancer, pregnancy, HIV)
• N: Neurologic signs or symptoms (confusion, focal neurologic signs, seizures, papilledema)
• O: Onset is new or sudden (especially if age over 50)
• O: Other associated features (head trauma, drugs or toxins, headache wakes you from sleep or gets worse with Valsalva, coughing or exertion triggers the pain)
• P: Previous headache history with progression or change in characteristics

If no high-risk features are present, a diagnosis of primary headaches can usually be provided by taking a thorough history and physical exam. For primary headaches, doctors must be able to differentiate one type from another to begin the right treatment. On the other hand, if the patient has high-risk features or the history and physical exam do not align with a primary headache, doctors must seek out the cause of secondary headaches. Recognising common patterns can be helpful here.

The most critical secondary headache diagnoses include Subarachnoid Hemorrhage, Cervical artery dissection, Meningitis and encephalitis, Dural sinus thrombosis, Ischemic or hemorrhagic stroke/cerebrovascular accident, Carbon monoxide poisoning, Acute angle-closure glaucoma, Idiopathic intracranial hypertension, Hypertensive emergencies, and Temporal (giant cell) arteritis. These conditions come with their own distinct symptoms and physical examination findings, and need to be promptly identified and treated.

Testing for Headache

When you go to the emergency room with a headache, the doctor will first perform a thorough examination and ask about any health history. Generally, the majority of headaches can be recognized through this initial examination as harmless types. However, in some cases, additional tests may be needed. There’s no one-size-fits-all approach, so further tests will be planned based on your individual situation and the evidence at hand.

Standard lab tests are mostly not helpful for diagnosing headaches, but they could be useful if a serious underlying cause is suspected. For instance, a pregnancy test might be required for a female patient having a headache accompanied by high blood pressure. In cases of suspected carbon monoxide poisoning, a carboxyhemoglobin level test should be conducted. If there’s a chance that your headache is due to a condition like giant cell arteritis, your doctor will order tests for inflammation markers like ESR and CRP. If these levels are normal but the suspicion persists, you might need treatment for giant cell arteritis while waiting on further test results.

Tests for problems in the blood clotting system could be helpful in patients suspected of experiencing cerebral venous thrombosis. Blood involvement can suggest infection or inflammation but it is not specific to any condition.

In some situations, patients may need scans to better understand what’s causing their headaches. Particularly if you have new neurological symptoms, sudden severe headaches, or if you are over 50 years old and just started getting headaches, your doctor may recommend having a scan. The need for imaging increases with certain risk factors like recent head trauma, changes in your state of consciousness, constant nausea and vomiting, and weak or absent reflexes among others.

A CT scan is typically the first choice for people who need scans because of vital headaches. However, additional targeted imaging like cerebral CT angiography may be needed depending on the specific condition being examined. If the cause of the headache is suspected to be a dural sinus thrombosis, an MRI would be the most effective. But if an MRI cannot be done, CT with CT venography would be an alternative.

Sometimes, a lumbar puncture and cerebrospinal fluid studies are needed in patients with headaches. Indications for this procedure include fever with changes in mental state, signs of meningitis, neurological deficits, and a history of HIV or other immune-compromising conditions. It can also be helpful in ruling out certain conditions like subarachnoid hemorrhage.

Note that these additional tests are primarily used to rule out potential life-threatening conditions and might not always reveal abnormalities. Always consider the advice of your doctor and remember that these tests should be used in conjunction with, not as a replacement for, clinical judgment.

Treatment Options for Headache

The main focus of treating primary headaches, which are recurrent, in the emergency room, is to reduce symptoms and provide needed support. It’s important to recommend that the patient seek follow-up care with a neurologist or primary doctor, for additional treatment options. Medical treatment aims to provide quick and lasting pain relief, while minimizing side effects. Headaches often come with nausea and vomiting, so medication should ideally be given through injection whenever possible.

It’s also crucial to manage the patient’s expectations. They should know that it’s common for headaches to come back, and they should know how to handle a recurring headache and when they need to return to the emergency room.

Here is a list of effective treatment options:

• Rehydration using Fluid: IV fluids have not been proven to relieve pain, but rehydration is vital for those with nausea and vomiting who may not be able to eat or drink orally.
• Antidopaminergic agents like prochlorperazine, chlorpromazine, promethazine, and metoclopramide: These drugs provide both pain relief and anti-nausea effects. However, they could cause extrapyramidal symptoms (motor system problems), which can be treated with a drug called diphenhydramine.
• Acetaminophen: This drug can provide good short-term relief, but there is a high rate of headache recurrence.
• NSAIDs like ibuprofen, ketorolac, naproxen, and diclofenac: These drugs provide excellent pain relief, but caution is needed for patients with a risk of bleeding.
• Triptans like sumatriptan: These are often used for preventing and stopping migraine headaches. They provide good long-term relief but should be prescribed with a follow-up plan due to their side effects.
• Corticosteroids like dexamethasone: These are shown to reduce recurrence of headaches, especially migraines, and can provide some pain relief when given with metoclopramide.

Cluster headaches can be treated with high flow oxygen. Opiates should be avoided, they might increase emergency room visits, lessen the effectiveness of other medicines, and have a high risk of addiction. Patients asking for opiates might be at risk of abuse and dependence.

Non-invasive sphenopalatine ganglion nerve block, applied intranasally using a long cotton-tipped applicator, is another treatment option increasingly used in emergency departments. Multiple trials have shown that it’s relatively safe and effective for treating primary headaches and facial pain syndromes.

Treatment of secondary headaches depends on diagnosing and treating the underlying cause.

What else can Headache be?

The list of conditions that might cause headaches is quite extensive. In addition to the conditions we’ve already mentioned, here are some more that could potentially result in headaches:

• Sinus infection (Acute sinusitis)
• Middle or outer ear infection (Otitis media or externa)
• Excessive fluid in the brain (Hydrocephalus)
• Disorders affecting the jaw joint (Temporomandibular joint syndrome)
• Problems related to the wisdom teeth
• Tooth decay
• Neck and spine nerve disorders (Cervical and paraspinal radiculopathies)
• Headaches caused by excessive usage of medication
• Symptoms arising from stopping or reducing the intake of certain substances (Withdrawal)
• Brain tumors
• Headaches that follow an event of spinal fluid removal (Post-lumbar puncture headache)
• Effects experienced after a concussion (Post-concussive syndrome)
• Viral infections
• Toxins
• Abnormalities with the blood vessels (Vascular malformations)
• Pituitary gland tumors

Understanding these possibilities can aid in correctly diagnosing and treating the source of the headaches.

What to expect with Headache

The outlook for primary headaches, which often come and go, can vary greatly depending on the specific type. These headaches frequently occur and pose a significant challenge to emergency and primary care providers. However, the good news is that they don’t lead to death or lifelong disability. While these recurring headaches can indeed cause short-term disability due to their distressing nature, they can be managed effectively with the help of a medical specialist.

It’s also worth noting that people can recover from chronic headaches, especially when they stop regularly using painkillers, stick to preventative medication, engage in physical exercise, and manage stress levels.

On the other hand, the outlook for secondary headaches, which are caused by underlying conditions, depends on what exactly is causing them. Many of these underlying causes require continued medical attention to alleviate symptoms. Some reasons for secondary headaches can be exceptionally debilitating or even lead to death. In such serious scenarios, healthcare professionals aim to quickly stabilize the patient, minimize overall impact, and ensure patient comfort to achieve the best possible results.

Possible Complications When Diagnosed with Headache

Primary headaches can lead to problems mainly because they can temporarily disrupt normal routine and functions. These disruptions may include things like missing work or a decline in productivity. When chronic primary headaches are treated, one potential issue to be aware of is medication overuse headache, also referred to as a rebound headache. This often happens when the body gets used to the pain relief medication, and the headache becomes unresponsive to treatment. The problem may even worsen quickly when the pain relief medication is suddenly stopped.

Secondary headaches can lead to complications that range from mild, temporary discomfort and disability to severe neurological disability, and in some cases, even death. Therefore, it’s extremely important for doctors to look for potential secondary causes of headaches. They should conduct a detailed primary and secondary check to ensure they can correctly manage the underlying causes of a patient’s headache, minimizing complications from delayed treatment.

Preventing Headache

For people dealing with primary headaches, it’s crucial to understand that these headaches are generally harmless and pose no long-term risks. Often, knowing this can lessen the impact the headache has on their quality of life. If these headaches keep coming back, individuals should consult a specialist. The specialist can offer suitable medication to prevent or stop the headaches. Plus, keeping a record of their headaches and being aware of potential triggers can help in reducing the frequency and enhancing the overall quality of life. Some patients may also find that lifestyle changes like getting adequate sleep or reducing caffeine intake improve chronic headaches. Individuals should be aware of the concept of rebound headaches, which happen due to overuse of medication, how to prevent them and manage their headaches properly.

Those experiencing secondary headaches need to be informed about the underlying cause and how to manage it effectively to lessen their symptoms. If a headache is due to a medical procedure or injury, they need to know which activities to avoid, for how long, and any warning signs which should lead them to seek immediate medical attention.