Headache is the fifth most common presenting chief complaint in emergency departments, and it is vital to quickly rule out life-threatening secondary causes. Though there are many medications, new and old, that can be used to treat primary headache, the evidence for their effectiveness can be conflicting.
Our recent issue Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches describes the pathology, workup, and treatment for migraine and other primary headaches based on the best available evidence, including novel medications, nerve blocks, and strategies for preventing postdrome recurrence.
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Here are a few key points:
- ED evaluation of headache can be summarized by the OPQRSTU mnemonic. Query the patient regarding: onset, provokes/palliates, quality, radiates, severity, timing, and under treatment.
- The physical examination focuses on excluding secondary causes of the headache. The neurologic examination is most important, and particular attention should be paid to the eyes.
- Results of the history and physical examination will dictate the need for further workup.
- Headaches may be episodic (<15 days/month) or chronic (≥15 days/month for 3 months).
- Chronic migraine affects nearly 2% of the population and is commonly seen in the ED.
- Chronic headache may be caused by or exacerbated by medication overuse headache (MOH), a secondary headache disorder.