You are called to the ward at night because a patient has a headache.
- What symptoms might you ask about?
The goal of assessing a patient with an acute headache is to determine if this is a benign or worrisome headache (i.e. intracranial haemorrhage, increased intracranial pressure, space occupying lesion, giant cell arteritis).
Symptoms to ask about include:
- Pain – onset, provoking/relieving factors, severity, location, quality, radiation, history or tension/migraine/cluster headaches
- Nausea/vomiting, fever, visual disturbances, neurological symptoms (parasthesias, motor weakness), jaw claudication, scalp tenderness
- Assess for altered level of consciousness
For symptoms suggestive of a raised intracranial pressure or intracranial haemorrhage – “thunderclap” headache, persistent unilateral headache, or headaches with vomiting – appropriate imaging +/- a lumbar puncture should be performed for diagnosis.
- Assuming there are no “red flags,” how would you treat this headache?
Treat with Acetaminophen 500-1000mg PO q6h (up to 4g/d).
Tylenol should not be used in patients with known or suspected liver failure.
- What if your therapy does not work?
NSAIDS may also be used for headache relief:
- Ibuprofen 400mg PO q4-6h
- Naproxen 500-750mg PO TID
NSAIDS should be avoided in patients with GI bleeds, GI ulcers and/or acute kidney injury.
- Clinch CR, Hébert FE. Evaluation of Acute Headaches in Adults. American Family Physician. 2001, 63:685-692. www.aafp.org/afp/
- McCulloch DK. Migraine and Tension Headache Diagnosis and Treatment Guideline. 2011. Online resource:1-16. http://thehub.utoronto.ca/family/wp-content/uploads/2013/07/Guideline-headache.pdf/