You can't assume headaches are benign
An elderly woman tells ED triage nurses she's had an excruciating, unrelenting headache for the past two days. She has a steady gait. She is alert and oriented without numbness, weakness, imbalance, difficulty with speech, or visual changes. She has no history of headaches. She does, however, have a history of atrial fibrillation for which she takes warfarin.
"That patient was my mother, with a subarachnoid hemorrhage," says Lorin Bacon, MS, RN, acute care nurse practitioner in the ED at Kaiser Permanente Medical Center in Roseville, CA.
Most often, a headache for several days is not an emergent matter, and an intracranial hemorrhage would drive most patients into the ED immediately, says Bacon. "For that triage nurse to recognize that this could be an emergent, potentially life-threatening event is remarkable," she says. "My mother could have been triaged to a clinic and waited for hours, and suffered a massive brain injury related to the buildup of blood and pressure in her head, and she could have died. She did not and is doing well without any untoward sequelae."
Would you be able to distinguish a migraine headache from a subarachnoid hemorrhage or ruptured cerebral aneurysm? Your diagnostic assessment is key, says David R. Vinson, MD, ED physician at the Permanente Medical Group in Roseville.
"Asking if this headache was gradual in onset, as opposed to sudden in onset, helps distinguish a migraine headache from a more worrisome alternative like a thunderclap headache," he says.
One in eight patients with a sudden thunderclap headache will have a ruptured cerebral aneurysm, notes Vinson. "Knowing the headache was gradual in onset makes the possibility of this kind of subarachnoid hemorrhage far less likely," he says.
To improve care of headaches, do the following:
• Don't overlook classic "red flags."
In addition to sudden onset, other worrisome signs are headache following head trauma, new onset of headache in patients older than 50 or patients with immunocompromise or malignancy, increased frequency or severity of headache, headache with concomitant systemic illness, and focal neurologic signs or symptoms, says Vinson.
Ask these questions at triage, says Bacon:
— Is this headache similar to one you've had in the past? How so?
— Are you experiencing any numbness, weakness, imbalance, difficulty with speech, or visual changes?
— Any recent trauma, head or otherwise?
— What medications do you take?
• Remember the patient's condition can change suddenly.
A patient may appear stable at triage and placed in a general exam room, but the patient may suddenly become unresponsive, with the CT scan revealing a huge head bleed, says Mary J. Ross, RN, BSN, CEN, charge nurse at the Emergency Medicine Trauma Center at Methodist Hospital in Indianapolis.
• Take a thorough history.
One woman told ED triage nurses she had a headache on and off for several months, which had been under the care of a primary care physician, recalls Ross. In addition, nurses learned that her family had complained of a change in the patient's personality and that the woman had a prior history of breast cancer.
"The brain is a common metastasis site," she says. "Along with these findings and her complaint of headache, the ED physician decided to do a head CT, which showed a huge brain tumor."
• Ask patients if the headache is similar to prior episodes.
If the headache is similar to previous ones, then the likelihood of more worrisome causes of headache is greatly reduced, says Vinson.
Document this information for ED physicians, urges Vinson. "I love it when I pick up a chart for a headache patient and the nursing assessment opens with '27-year-old migraineur with gradual onset yesterday of her customary headache,'" he says. "That kind of assessment is invaluable."
• Identify what medications the patient has tried at home.
"This helps guide our pharmacotherapy," says Vinson. "If the patient just took her triptan, then I know I have a more limited repertoire of therapeutic options."
Many migraine patients respond well to intravenous (IV) antiemetic medications such as metoclopramide and prochlorperazine, notes Vinson. "Asking if the patient has received these medications in the past is useful information."
• Assess for medication side effects.
Patients given IV dopamine-blocking anti-headache medications may develop a side effect of restlessness known as akathisia, notes Vinson.1 "Fortunately, the incidence of akathisia can be reduced in half if IV diphenhydramine is given prophylactically," he adds.2
If IV metoclopramide or prochlorperazine is given and restlessness is noted, diphenhydramine or lorazepam can be used for treatment, Vinson says.3,4
• Evaluate whether medications have been effective.
"It's not uncommon that the first round of medications might fail to abort the headache," says Vinson. "Sometimes, a second round of drugs is needed."
Some migraineurs will not respond to standard antimigraine treatment, notes Vinson. "For many of these refractory cases, parenteral opioid medication may be indicated," he says. "Sending a migraine patient home with continued pain increases their chances for a return visit."
References
- Vinson DR. Development of a simplified instrument for the diagnosis and grading of akathisia in a cohort of patients receiving prochlorperazine. J Emerg Med 2006; 31:139-145.
- Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: A randomized, controlled trial. Ann Emerg Med 2001; 37:125-131.
- Vinson DR. Diphenhydramine in the treatment of akathisia induced by prochlorperazine J Emerg Med 2004; 26:265-270.
- Parlak I, Erdur B, Parlak M, et al. Midazolam vs. diphenhydramine for the treatment of metoclopramide-induced akathisia: A randomized controlled trial. Acad Emerg Med 2007; 8:715-721.
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