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Acute headache management in emergency department. A narrative review

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Abstract

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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Authors and Affiliations

  1. Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D’Annunzio University of Chieti, 66100, Chieti, Italy

    Maria Adele Giamberardino & Giannapia Affaitati

  2. Institute of Surgical Pathology, G. D’Annunzio University of Chieti, Chieti, Italy

    Raffaele Costantini

  3. Department of Clinical Pathology, University of Sassari, Sassari, Italy

    Martina Guglielmetti

  4. Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy

    Martina Guglielmetti & Paolo Martelletti

  5. UOC Medicina Interna, AOU Sant’Andrea, Rome, Italy

    Paolo Martelletti

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  1. Maria Adele Giamberardino
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  2. Giannapia Affaitati
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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). https://doi.org/10.1007/s11739-019-02266-2

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