Is it just
What this article is: A concise practical approach and overview for nurses new to the Emergency Department setting who confront common complaints of headache (selected etiologies) and of Stroke (ischemic or hemorrhagic). The emphasis is on recognizing common or significant syndromes and providing appropriate care rapidly.
Limitation: This outline was developed in an academic tertiary Emergency Department with ready resources of radiologic imaging, an Interventional Neurovascular team of stroke specialists, etc. , the presence of which shape the response and may not be applicable in other settings.
What this article does not do: Does not consider all possible
etiologies of headache or deeply explain the
Our disclaimer fully applies to all and every part of this article.
The shortest triage interview I ever had was a man, holding a wheelchair indicating his friend therein, who said "He has a fever, a headache, and a stiff neck." A glance showed a flushed, sweaty man slumped in the wheelchair with a torpid, toxic appearance, and clearly "altered mental status." Triage was complete. "I'm taking him straight back. Register him there, please!"
Contrast that with the chief complaint of a "full-moon" type of patient: "I've had this headache for thirty years!" Do you get a different sense of urgency?
I did not know then the rare parasitic organism that killed the first patient, but the essential triage elements for high priority were clear: severity, infectious symptoms, meningeal irritation, and altered mental status.
Most headaches seen in the ED are simple or an associated symptom of the patient's problem. However, we need to be vigilant for headaches that are clues to dangerous problems because although headache is a nearly universal part of the human experience, it is unusual for "the average person" to come to the hospital with an "ordinary" headache. Doing so (with the cost, inconvenience, and discomfort of an ED visit) should be a marker for concern. The reason the patient comes will be because of what seems unusual or frustrating: i.e.,
Useful HPI would be time and manner of onset, description and course, pain scale rating, other symptoms, efforts and effect of self-care (some may mask fever). A good mnemonic would be PQRST:
Questions regarding PMH and PSH may elicit hypertension, cancer which may be metastatic, TIAs, URI or allergy symptoms, sinus or cranial surgery, ventriculo-peritoneal shunting of CSF from hydrocephalus. Occupation may suggest a toxin, environmental problems, or exposure to pathogens (childcare worker, or foreign travel). Habits such as alcohol or intravenous drug abuse which increase risk.
Neurologic signs and symptoms such as lethargy, any loss of consciousness, disorientation or confusion, dysarthria, visual changes such as photophobia, blurring, diplopia, halos around lights, speckles or jagged streaks, ataxia or gait disturbance, clumsy use of extremities, nausea or vomiting may be significant and should be repeatedly sought. These should have high priority.
Our goals then are to:
International Headache Society
World Headache Alliance
e-medicine.com Emergency Medicine Online Text: Headache, Tension
e-medicine.com Emergency Medicine Online Text: Headache Migraine
JAMA Migraine: Migraine Information Center Peer Reviewed Resources
The American Headache Society (AHS)
The American Council for Headache Education (ACHE)
The Migraineur's Bill of Rights
Pharmacological Management of Acute Attacks
Thumbnail portraits of selected headache syndromes:
Everyday, garden-variety, usually eased with simple analgesics or codeine/oxycodone, rest, minimization of distracting stimuli (quiet, dim room), relaxation therapies such as ice, massage, or guided imagery.
Coincident with or following URI/Allergies/rhinorrhea/post-nasal drip (particularly when drainage has thickened and plugged). Usually afebrile or low-grade fever only. May have marked congestion, sinus pressure, tenderness, worsening of headache with postural change (tying shoelaces), possible radiation to ears or teeth. Diagnosis is usually clinical. Occasionally, sinus films or CT may be ordered.
Temporal Arteritis (Giant Cell Arteritis):
This headache, typically in an older patient (>50 years), often described as unilateral and throbbing, associated with tenderness at the temples is a manifestation of a vasculitis which if untreated may lead to blindness. An important test to send is an Erythrocyte Sedimentation Rate [ESR] which can indicate an inflammatory process; send this in a "lavender/purple top tube " (EDTA); it can be "added-on" to the CBC up to five hours after draw time.
Hydrocephalus or Shunt Malfunction:
Patients with disturbance of the circulation or resorbtion of cerebrospinal fluid (often due to birth injury, cranial surgery, or previous bleed) may sustain increased pressure on the brain. If a ventriculo-atrial (small children), or ventriculo-peritoneal shunt has been previously placed (the line may be seen or palpated in the neck on either or both sides), it may not now be functional due to fibrosis at the outlet. A CT scan would be done (and compared with previous) to determine if there are enlarged ventricles and sulcul flattening consistent with the increased volume and pressure. The neurosurgeon may "pump" an Ohmaya reservoir to check functioning, and may "tap" the reservoir (with a butterfly needle) to obtain CSF. The patient will need admission for further function studies or emergency revision of the shunt. Symptoms include those of Increased Intra-Cranial Pressure.
Headache may be part of the presentation of patients with brain tumor, either primary or metastatic (especially of breast or lung). Headache may be worse upon wakening and then decreasing or vanishing during the day with upright activity due to the influence of gravity.
Post-Spinal Headache or Dural Leak:
Patients may present with headache after an LP in "the Doctor's office" (or hospital), and some dehydration. While the mechanism is not fully understood, it is often relieved with acetaminophen with codeine or oxycodone. It is sometimes found useful to infuse a liter (more if dehydrated) of normal saline with 500 mgm to 1 gram of Caffeine and sodium benzoate injection added. The patient may need to be reminded that this large a dose of Caffeine may interfere with sleep, or cause some jitteriness.
Prevention is believed to be increased by using a smaller gauge (22ga) needle, and resting prone for a while (lessens pressure against the wound sinus), and possibly with hydration (but not supported by some studies).
If the patient has persistent recurring "spinal headaches" or leakage of CSF from a dural defect following a procedure, they may come for a "blood patch" wherein an autologous specimen of blood is injected into the sinus tract of the leak and clots forming a resorbable "dam".
Patients with intravenous drug abuse, complicated peri-orbital or sinus infections, or complications of surgery may have abscesses in the brain. Fever and altered sensorium will probably accompany the headache. Expect to do blood cultures, etc., give antibiotics early, and do CT scanning, possibly with contrast, MRI imaging may also be used.
Patients from Mexico or exposed to these parasitic worms which encyst in the brain, may present with seizure as well as headache or fever. Expect CT scanning as part of the diagnostic process.
The classic triad of fever, headache, and stiff neck should always raise the question of Meningitis. Blurred or double vision may be present. Assess delirium. Have the patient fully flex his neck (with mouth closed) and attempt to touch his chin to his chest. Ask for effort despite pain. Record the gap between chest and chin by the number of fingerbreadths. Check range of motion and general suppleness.
Antibiotics should be given at the earliest possible moment, even before CT or LP if clinical suspicion is strong. Have someone else prepare the antibiotics while the IV is being started and the cultures and labs drawn. As blood work is done, begin antibiotics. It will take a while before the antibiotics reach the urine or the CSF, so do not delay.
If there is strong concern about Increased Intra-Cranial Pressure, expect a CT scan first (to avoid brain herniation by removal of CSF). If papilledema can be excluded by funduscopic examination of the eyes with an opthalmoscope by the physician (i.e., discs are sharp), then it may be deemed safe to do the LP before CT (LP makes the diagnosis; CT just shows that it is probably safe to do the LP). Purulent CSF becomes increasingly opalescent and turbid. If the CSF glucose is down and the CSF protein is up, this favors the diagnosis.
In young children, expect an order for dexamethasone (Decadron®) to help protect against hearing loss and other potential neuro deficits.
Severe migraine may present as intractable headache failing home prophylaxis or abortive therapies and frequently irritable with unrelieved pain, exhausted, and dehydrated from nausea and vomiting. Dark glasses may be worn even at night due to photophobia.
HPI should include a comparison with the "usual" prodrome and headache; is it different in any way? What self-treatment has already been done and to what effect? "What usually works to relieve your headache when you feel like this?" If narcotics are likely to be needed, does the patient have a "ride", responsible adult companion, or taxi to see them safely home?
Caveat: Remember that this may not be a migraine again, but in fact may represent a new neurological event, so review for fever and chills, neck stiffness, and other neuro signs. Also, try to establish how and by whom the diagnosis of migraine was established, any studies or clinical trials of common anti-migraine medications, etc.; ---patients may come in announcing they "have a migraine" as a self-diagnostic impression ("a really bad headache" or "sick headache") perhaps influenced by advertising or the helpful intentions of family.
Treatment includes a prompt evaluation, a soothing environment, and adequate analgesia to relieve the headache, antiemetics and hydration may be needed and often are more important than full relief of the headache. Many analgesics and sedatives have been tried; there is no perfect medication. Patient-reported medication failures and intolerance or allergy to medications may sharply limit the available choices.
Do not be surprised or indignant if the patient requests to be "put to sleep" or "knocked out", or if soon after reporting that the headache is better, she wishes "to go home and get some sleep". While it is not the intended goal or our treatment, the majority of migraineurs find that if sleep can be achieved, even by sedation, the headache is less or gone upon awakening. Thus, almost any medicine that can help the patient sleep with the headache may have been tried at one time or another.
"Frequent Flyer" patients are asked to contact their primary care physician or neurologist for a protocol" or care plan to be filed with the Emergency Department to guide and limit their care within a contract. Most episodes should be manageable within home care by the prescribing physician, although care may need to be optimized in collaboration with the Pain Management Clinic. While we stand ready to evaluate any new problem, and to provide "crisis" treatment in collaboration with the responsible physician, episodes of recurring chronic pain is best managed by an ongoing provider who can monitor response to treatment and alter as needed.
Caregivers should be wary
of skeptical opinions alleging "drug-seeking behavior" and carefully consider
offered evidence. While such behaviors exist, it is difficult for patients to adequately
get relief from pain syndromes without frequent visits or changes of provider or care
Infrequently, a trial may be made of nasal 4% topical Lidocaine applied by drops by a syringe with cannula to a nerve plexus. (The patient is supine, with head dangling off the end of the bed.) It is said that about 70% may achieve prompt relief this way.
Studies show that proclorperazine (Compazine®) works as well as anything else in easing migraine, presumably through its antiemetic property and sedation. Metoclopramide (Reglan®), is also used in many places. However, often with fully established or intractable headaches, narcotic analgesics may still be needed. Remember, as for Meperidine, --Our Institution's ED is a "Demerol®-free Zone."
An important new class of drugs for migraine is that of "the triptans", of which Sumatriptan (Imitrex®) is the prototype and that which is stocked in our Pyxis MedStation. No more than two doses of Sumatriptan (Imitrex®) should be given, then change to a narcotic analgesic. Find out more about this class at http://www.rxlist.com/cgi/rxlist.cgi?drug=*triptan. http://www.rxlist.com/cgi/rxlist.cgi?drug=*triptan
One important caution with ergot drugs such as (DHE-45®) Dihydroergotamine Mesylate 45) is that chest pain can occur (due to vasoconstriction) which can be a cardiac event, accompanied sometimes by an oppressive sense of doom. One may also notice coolness and pallor of the extremity. It may be wise to have an EKG before giving to persons over fifty years of age. Give slowly over a least two minutes and pre-medicate with an antiemetic. Dilute, if using a very small vein. Find out more about DHE at http://www.rxlist.com/cgi/generic2/dihyergmes.htm. http://www.rxlist.com/cgi/generic2/dihyergmes.htm
Patients may present with headache, "dizziness", nausea and vomiting, when hypertension is uncontrolled (SBP>200 torr DBP>100 torr). Often, assurances are needed that this is not a "stroke", in and of itself, but symptoms will resolve as BP moderates. However, it should be emphasized that anti-hypertension medicines must be continued at all times, unless changed by the physician, as sustained hypertension can damage end-organs (brain, eyes, heart, kidneys) without feeling symptoms; that hypertension "doesnt go away, --it is controlled."
Occupational exposures to this odorless, colorless, tasteless product of incomplete combustion may have a recurring pattern of headache at work that clears after removal to non-toxic atmosphere. (It may be confused with "stress.") Besides headache, there may be malaise, cognitive impairment, nausea, vomiting, and weakness. Do not expect to see a "cherry-red skin color." Skin color will initially be normal and then pale in living subjects. In a family or group-living situation, others (including pets) may be affected also, often by ascending proportion of size given equal exposure (like the Miner's Canary), or the youngest and eldest may succumb first. As it is often due to defective heating equipment, occurrences may increase in winter. It also may be mistakenly thought to be "Flu" by the family; A pattern may be noticed in which the family "improve" on the way to or in the hospital, and return, perhaps in repeated fashion, after becoming ill again at home. Remain suspicious of these possibilities; you may prevent ultimate disaster.
Brain Attack": TIA/RIND; CVA
Major Didactic Resources Online
e-medicine.com Emergency Medicine Online Text:
Neurology has long been chided as a specialty that made elegant diagnoses of conditions about which nothing could be done. This is no longer so. With neurovascular interventions available now, it is possible to rescue some patients from a worse neurological outcome than would otherwise be expected. The call is out to aggressively treat fresh stroke as a "Brain Attack"; that is, with the same vigor with which we treat heart attack.
The very name, "Stroke", speaks of old fears of persons struck down by the hand of God, so fateful and doom-laden in its finality.
Is it a Transient Ischemic Attack, Reversible Ischemic Neurological Disease, or a Cerebro-Vascular Accident? Only time (and CT or MRI) will tell. TIA describes evanescent neurological symptoms that wane within 24 hours; RIND describes symptoms that resolve after 24 hours; CVA names the accomplished infarct or bleed. However, generally, TIAs are a brief course of minutes (often a matter of "what was that?").
Eighty percent of the 500,000 strokes per annum are ischemic. And, it is these about which we can now do something with prompt thrombolysis to attempt salvage of threatened brain tissue. However, recognition, preparation, and action must be swift because of the limited time frame. Neurology is the primary admission service.
The key fact to establish is the witnessed time of onset of symptoms, as the window for intervention is brief. If less than 3 hours have elapsed, thrombolysis can be done, in selected cases some attempt can be made up to 6 hours. However, if the patient went to bed well, but awoke with symptoms without a clearly witnessed event, the assumption must be that onset is the same time the patient went to bed/was last seen well.
If Glasgow Coma Scale is ~ 8, and endotracheal intubation (with Rapid Sequence Intubation and paralysis) is planned to protect the airway, the neurology service will want to examine the patient (if possible) before paralysis and sedation confound the neurological exam. Try to get them down before this happens.
If the stroke is hemorrhagic, Neurosurgery will consult, and be the admission service, unless only comfort care can be offered to the moribund patient. Patients with bleeds tend to be "sicker" with rapidly evolving symptoms and complications, but no symptom pattern can definitively identify ischemic or hemorrhagic etiology.
CT is about 95% effective in excluding a bleed. It will usually detect a 1 cm hematoma. Very fresh strokes may not yet show changes; 12 hours are sometimes needed to elapse. Some large infarcts may later transform and subsequently bleed, so it is not uncommon for serial CT exam to be done in the course of hospital stay. When "ruling out" a bleed, a lumbar puncture will generally be done after CT, to find red blood cells or xanthrochromia (a supernatant layer of broken down rbcs indicating an earlier bleed).
Send coagulation studies (blue top tube) immediately with the initial labs, and hold a blood bank "type" tube and "check specimen" in case of operative treatment.
Remember to do an EKG early. Since ischemic stroke represents part of atheromatous disease, and that emboli can originate from a heart with atrial fibrillation or hypokinesis from myocardial infarction, there may also be a cardiac event accompanying or precipitating the stroke.
Alcoholics and the elderly, due to cortical atrophy and shearing forces, have increased likelihood of sub-dural hematomas with minimal trauma.
Please check the attached documents for thrombolytic protocol treatment.
National Institute of Neurological Disorders and Stroke
The American Academy of Neurology
AAN's Public Information on Stroke & "Brain Attack"
American Stroke Association, a division of American Heart Association
Heart And Stroke AZ Guide
National Stroke Association
American Association of Neuroscience Nurses (AANN)
The American Council for Headache Education (ACHE)
Neurosciences On The Internet
Trauma, Emergency, and Intensive Care Neurosurgery Index
UNC's Online Neurosurgery Resident's Handbook
The Stanford Stroke Center
An exemplar care pathway for Acute Ischemic Stroke is published in JEN:
Journal of Emergency Nursing
Thrombolytic therapy for patients with acute stroke in the ED setting
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