Headache management

Approach to acute headache

Headache is a common but challenging presentation in the Emergency Department because it requires balancing symptomatic relief with rapid identification of life-threatening conditions.

Headaches are broadly classified into:

• Primary headaches, which are neurological disorders and include:

  • Tension headache

  • Cluster headache

  • Migraine

• Secondary headaches, which result from an underlying pathological process such as infection, malignancy, or other organic diseases.

Differential diagnosis

Sudden-onset severe headache

Consider the following conditions:

• Subarachnoid hemorrhage

• Cerebral venous thrombosis

• Hypertensive emergency

• Adrenal emergencies

• Pituitary emergencies

Headache associated with altered mental status

Consider the following conditions:

• Meningitis

• Encephalitis

• Intracranial tumor

• Space-occupying lesions

• Stroke

• Subarachnoid hemorrhage

Headache associated with fever or systemic illness

Consider the following conditions:

• Hypoglycemia

• Fever

• Meningitis

• Malaria

• Brain abscess

Investigations

Investigations should be guided by the patient's clinical presentation.

Recommended investigations include:

• Malaria test

• Random blood glucose

• Blood gas analysis

• Point-of-care urine dipstick

• Urinalysis

• Cerebrospinal fluid (CSF) analysis

• Point-of-care ECG

• Bedside ultrasound

• Serum electrolytes

• Serum creatinine and urea

• Point-of-care lactate

• Urine pregnancy test, where indicated

• Radiological investigations:

  • X-ray

  • CT scan, where indicated

Pharmacological treatment

Oral analgesia

Use one of the following:

Paracetamol (PO)

• Adults: 1 g every 8 hours for 3 days.

• Children: 15 mg/kg every 6 hours as required, up to a maximum of 4 doses in 24 hours.

OR

Ibuprofen (PO)

• Adults: 400 mg every 8 hours for 3 days.

• Children: 5–10 mg/kg every 8 hours for 24 hours.

Analgesia for severe pain or for patients unable to take oral medication

For severe pain, or when oral medication cannot be administered, use one of the following:

Tramadol (IV)

• 50–100 mg stat.

OR

Morphine (IV)

• 0.1 mg/kg stat.

OR

Paracetamol (IV)

• 1 g stat.