NNC CMU
Primary Headache in
Emergency Setting
Surat Tanprawate, MD, MSc(Lond.), FRCP(T)1, 2
1Division
NNC CMU
Primary headache in ER
Cause
Vascular disorder
CADASIL, MELAS,
aneurysm, AVM, CAA,
carotid dissection, TIA/
Stroke, temporal arteritis
systemic hypertension
Non-vascular disorder
pineal cyst, neoplasm
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Suggestive features
Age of onset > 60
Progressive headache
Sudden onset
Prolonged aura
Atypical aura
(eg.hemiparesis)
New headache features
NNC CMU
Case record of symptomatic TACs from CMU
No.
age/sex
Presenting symptoms
Diagnosis
duration
of headache
PH like symptom,
Vertibral artery
numbness
dissection with medullary
- other
abnormal
neurological
(response to Indomethacin)
infarct
examination
Arterio venous fistula
CH likeof
symptom
after cavernous sinus
- sign
pituitary dysfunction:
thrombosis
Galactorrhea, impotence,
Nasopharyngeal
PH like headache
testicular atrophy
carcinoma with cervical
(response to Indomethacin)
carotid artery invasion
- persistent horners
syndrome
- Triggered
by changing
standing
CH like headache
Pituitary
tumor
-
57 Y.O.
51 Y.O.
60 Y.O.
30 Y.O.
sympathetic5
63 Y.O.
parasympathetic
dysregulation
CH like headache
Cavernous sinus
meningioma
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Migraine variant / with red flag signs
Acephalalgic migraine
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Migraine complication that may present in ER
Migrainous infarction
Migraine Emergency
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Character of Migraine at ER
Ideal medication
high efficacy
rapid onset
Severity of accompanying
symptoms (25%)
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Targeting acute migraine
medication
1. Directed contraction of dilated
cranial extracerebral blood
vessels
2. Suppression of neuropeptide
release from peripheral nerve
ending around blood vessels
5-HT1B
5-HT1D
5-HT1F
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Evidence of Dopamine
Dopamine and Migraine
attacks
system and Migraine
Increase alleles of DA D2 receptor
(DRD2) gene in migraine with aura
Biochemical studies: DA, HVA,
DOPAC level (CSF, platelet,
plasma)
Drug trial in acute treatment
(antidopaminergic agents)
DA modulate trigeminovascular
transmission
Migraineous phenomena in
dopaminergic agonist therapy
Mascia J and Shoenen. Cephalalgia 1998;18:174-182
Akerman S, Goadsby PJ Cephalalgia, 2007, 27, 13081314
NNC CMU
Acute migraine therapy ER
Dopamine antagonists
Opioids (meperidine,
morphine, tramadol)
Prochlorperazine,
chlorpromazine iv
Dexamethasone iv
Metoclopramide iv
Sodium valproate iv
Haloperidol, droperidol iv
Magnesium sulfate iv
Lidocaine intranasal
Sumatriptan sc
NNC CMU
AHRQ Effective Health Care Review
Helping Clinician Make Better Treatment Choices
1. Ability to achieve pain-free status
Neuroleptics, NSAIDs, and Sumatriptan improve the likelihood of
achieving pain-free at various time point after administration
- Sumatriptan at 30-120 mins (RR = 4.73)
- Neuroleptics (prochlorperazine, chlorpromazine, droperidol) at 60 mins (RR =
3.38)
- NSAIDs at 60-120 mins (RR = 2.74)
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3. Ability to reduce pain intensity
Pain intensity measurements at time points after administration are
reported on a 100-point visual analog scale (in mm).
- Neuroleptics (chlorpromazine, haloperidol, prochlorperazine) at 30
mins to 4 hrs (MD = -46.59)
- Metoclopaminde at 30-60 mins (MD = -21.88)
- Opioids (meperidine, nalbuphine, tramadol) at 45-60 mins (MD =
-16.73)
- Sumatriptan at 30 mins (MD = -15.45)
Neuroleptics (chlorpromazine) reduce pain intensity more than
metochopramide (MD = 16.45)
NNC CMU
AHRQ Effective Health Care Review
Helping Clinician Make Better Treatment Choices
5. Adverse event
>> akathisia after treatment with a neuroleptic agent or
metoclopramide are about 10 times greater than with placebo.
>> The risk of sedation is common after treatment with
metoclopramide or prochlorperazine (17% for both).
>> The most common adverse effects from dihydroergotamine
include pain or swelling at the injection site, intravenous site
irritation, sedation, digestive issues, nausea or vomiting, and
chest symptoms (palpitations, arrhythmia, or irregular heartbeat).
AHRQ:The Agency for Healthcare Research and Quality
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Dexamethasone
IV in ER setting
14 studies (56%) used IV Dexamethasone
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Drug showed weak evidence, but may be used
Magnesium sulfate IV
Sodium valproate IV
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A RCT of MgSO4 (2g iv) vs Metoclopamide (10mg iv)
vs Placebo in acute migraine attacks in ER
120 migraine patients
Metoclopramide
- magnesium
- - - - placebo.
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Occipital nerve block(ONB) in acute and transitional
therapy in migraine
Reference
Intervention
Results
Study design
97
A single or repeated
GON block(s) using
lidocaine and
methylprednisolone
27
Retrospective
14
Retrospective
19
Prospective, noncontrolled
*Pain reduction after GONB as soon as 3 minutes and remained about 6 months
Levin M. Neurotherapeutics. 2010 Apr;7(2):197-203.
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Occipital nerve block(ONB) in acute migraine
2 cm.below
2 cm.lateral
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Occipital nerve block in migraine - a case study
Pt.NO.
Before
5 min
2nd
3rd
Before
5 min
2nd
3rd
Occipital
tenderness
Allodynia
Before 5 min
HIT-6 scale
2nd
3rd
Before
2nd
3rd
60
64
60
58
52
56
60
40
60
78
75
68
60
36
66
54
60
62
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Other primary headache
that may present at ED
Cluster headache
Hypnic headache
Primary exercise/cough
Primary thunderclap headache
Primary headache associated with sexual activity
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Cluster headache acute therapy
EFNS recommendation (2006)
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Hypnic headache (HH)
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Clinical findings in patients with hypnic headache (n=96)
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Acute treatment used for hypnic headache attacks
Treatment
Number of
patients
Caffeine
Efficacy
Response rate
(A+B/n, %)
None
Partial
Good
19
15
84
Caffeine containing
analgesics
10
60
ASA
66
Triptan
34
29
14
NSAIDs
38
34
10
Acetaminophen
15
12
20
Oxygen inhalation
12.5
Ergotamine derivative
60
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Primary Headache associated
with sexual activities (HSA)
2 types
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Management at ED
short-term prophylaxis
long-term prophylaxis
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Primary thunderclap headache (PTCH)
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Management
Acute therapy - no