Just A Headache?

LEARNING OBJECTIVES

• Review symptoms of headaches
• Discuss various headache types
• Review prehospital treatment for the headache patient

Click here to access a 20-question review test for your training purposes.

     At 1428, your unit is sent to a private residence for a reported possible stroke. Upon arrival, an obviously worried family member takes you to a back room, where you encounter a 33-year-old female lying in a recliner. The room is well kept, and you note the lights are off, with just a bit of sunlight coming through the closed curtains.

     As you introduce yourself and your partner to the patient, you note she is breathing, and her verbal response is coherent and clear. You also see that she is clearly anxious. When you ask how she is feeling, Mary tells you that she awoke from a nap with severe right-sided head pain and she has lost her peripheral vision. "It's gone black," she says. Her vital signs show a strong and regular pulse of 94, an unlabored respiratory rate of 18, and blood pressure of 154/90. You administer the Cincinnati Stroke Scale (CSS) and don't notice any deviation from a normal response. Mary denies allergies to medication, says she uses seasonal allergy medication, and denies specific past medical history.

     You administer O₂ at 15 LPM via a non-rebreather mask, establish an IV of normal saline and check her blood glucose, which is 94. As you move the patient by gurney to the ambulance and prepare for transport, she begins to complain of nausea and then vomits. Your transport decision is an emergency facility that has head CT available. You arrive at the hospital after an approximately 25-minute transport, provide your hand-off report to the staff taking over her care, complete your paperwork and check on Mary prior to returning to service.

     Approximately four hours later, you return to the same hospital with another patient. After turning this patient's care over to the staff, you ask about Mary and learn that her CT was read as normal and her diagnosis was acute migraine headache. She was medicated for pain control and discharged to follow up with a neurologist.

     Your initial impression included consideration of a possible stroke, and you are a little surprised to find this was ruled out in light of her visual disturbances and the severity of her headache. A number of headache types may produce or carry associated symptoms that mimic a stroke or other potential diagnosis. It is important to remember that in the prehospital setting, it is nearly impossible to make such a diagnosis, and EMS providers should avoid snap assessments that may lead to treating a patient inappropriately.

HEADACHE TYPES

     Following are some symptoms and patient presentations that are common with different headache types.

TENSION HEADACHE

     This patient typically presents with a chief complaint of head pain described as a tight band around his head that may be heavy or oppressive. In tension headache, the pain is most often described as being on both sides of the head, and there may be some referred pain to the patient's neck.

     Getting a handle on how much head pain a patient is experiencing may be extremely difficult. A good assessment for head pain is to note the patient's activity level. Patients experiencing a tension headache will be able to perform what are known as activities of daily living (ADL), such as getting out of bed, walking around the house, and descending or ascending stairs, without the pain interfering or limiting these activities. It doesn't mean they don't have pain; it is just an indicator of pain severity and that their activity does not increase the pain.

     It is not uncommon for a patient with a severe tension headache to also complain of nausea and vomiting, which often leads to a 9-1-1 call. The patient may have a history of tension headache, but has never experienced nausea or vomiting with it. It is not uncommon for this patient to complain of sensitivity to light (photophobia) or sound (hyperacusis), but not both.

     As the name implies, tension headache is due to muscle tension. Characteristically, the muscles of the head and neck have contracted very tightly for a prolonged period of time, due to physical exertion, reading intensively, poor posture, work habits, or, of course, retaining stress. Most individuals, EMSers included, will experience episodic tension headaches; however, some may experience tension headache on a more frequent basis. People who have tension headache greater than 15 days a month are considered to have chronic tension headache.¹

     The majority of folks who experience a tension headache find relief with over-the-counter (OTC) pain medications like ibuprofen, acetaminophen or aspirin. Cold compresses, stopping the activity (e.g., reading, posture change), along with relaxation activities may also provide relief for the individual.

MIGRAINE HEADACHE

     More than 23 million people suffer from migraine headache in the United States—more than have diabetes, epilepsy or asthma.^1–4 Migraines are considered to be a vascular headache, and their signs and symptoms have been found and well-documented on papyrus as far back as ancient Egypt. About one in eight adults suffers from migraine; women are two to three times more likely to experience migraine headache than men. Migraine headache is most commonly found in the 25- to 34-year-old age group.¹

     Migraine pain is usually described as a moderate to severe "throbbing" or "hammering" headache, typically on one side of the head. The pain will prevent activities of daily living and will increase with exertion.⁵ While the individual experiencing a tension headache is able to go up and down stairs, or perform household or office activities, the migraine sufferer will find the pain too debilitating to do so.

     Patients experiencing a migraine attack, as it is often referred to, may complain of photophobia and sensitivity to sound. This is a typical complaint that may be used to differentiate it from a tension-type headache. Associated nausea and vomiting are also very common for the migraine sufferer.

     Migraines may be classified as either "common" or "classic." Common migraines do not have any warning signs or symptoms, while classic migraines do have a warning in the form of an aura.⁶ Patients may have migraines regularly on a weekly or monthly basis. For women, this may occur relative to their monthly menses cycle, triggered by fluctuating hormone levels. Ovulation, birth control pills and the birth control patch may also be contributing factors. Some victims, on the other hand, may go months or even years between attacks.

     In general, a migraine headache may last from four to 72 hours. Most individuals with diagnosed migraine headaches understand their condition better than EMS providers do. It is important for us to question why this patient called 9-1-1 when they already know what the problem is. It is key to ask what is different about this headache. If the duration of the headache is longer than 72 hours, consider what is known as a complicated migraine.¹ It would also be appropriate to ask the patient if there is anything else unusual about this particular headache, such as an aura.

     The aura, which is caused by cerebral vasospasm and spreading cortical depression, is often described as visual disturbances or changes. It may come on over a period of 10 to 30 minutes. Patients may describe spots before their eyes, loss of peripheral vision or even complete loss of vision, as well as numbness or tingling of the limbs. Slurred speech or changes in speech patterns may also present as an aura.⁵ It is also common for patients to experience protracted vomiting, diarrhea and hypovolemia. It is easy to understand why a patient or family member would be alarmed, as these symptoms certainly say stroke until proven otherwise.

     Patients who experience some neurological dysfunction with their headache are classified as having a complicated migraine. The area of the body affected by the dysfunction is related to the area of the brain where the headache is occurring. A vertebrobasilar migraine would be associated with symptoms affecting the brain stem. These patients would report vertigo or double vision¹ and may be reported by a bystander or family member to have passed out or fainted. The symptoms from a complicated migraine may last only a few hours or up to several days.

     Patients with a history of migraine headache are often prescribed triptans, or serotonin receptor agonists. The most commonly prescribed are sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), and zolmitriptan (Zomig). These are usually found in tablet form or as a nasal spray; however, they may also be prescribed as a self-administered injection.⁶

     Ergotamine derivatives and Midrin, which is a combination of the drugs isometheptene, acetaminophen and dichloralphenazone, are other medications used by migraine sufferers. Nonsteroidal anti-inflammatory drugs (NSAIDS), which are over-the-counter medications, may also help arrest a migraine in some individuals.⁶

     Patients who experience migraine headaches as frequently as three or more times per month are often prescribed medications to help reduce the number and intensity of the attacks. Most commonly prescribed are beta-blockers, such as propranolol (Inderal); antidepressants, including tricyclics like amitriptyline (Elavil) or fluoxetine (Prozac, Sarafem), paroxetine (Paxil), or sertraline (Zoloft); anticonvulsants like valproic acid (Depacon, Depakene) or divalproex sodium (Depakote), and calcium channel blockers such as verapamil.¹

     The exact cause of migraine headache is not fully known; however, it is believed that blood flow in the brain is the key component. At the start of a migraine, blood vessels in certain parts of the brain constrict and reduce blood flow, at which time the symptoms described as an aura occur, along with visual disturbances, numbness, tingling and slurred speech. Minutes to hours later, the blood vessels dilate, blood flow increases, and the onset of migraine occurs.⁵ While the changes in blood vessels and blood flow are not completely understood, it is believed that certain triggers make it more likely for the migraine sufferer to experience an attack.

Migraine Headache Triggers

• Bright or flashing lights
• Loud noises
• Changes in sleep pattern
• Allergic reactions
• Alcohol or caffeine
• Smoking or exposure to smoke
• Skipping meals
• Emotional stress
• Certain odors or perfumes
• Certain foods containing tyramine (red wine, aged cheese, smoked fish, and some beans)
• Foods containing MSG or nitrates (hot dogs, bacon, salami)
• Other foods, including: chocolate, nuts, peanut butter, citrus, pickled or fermented foods

HEADACHE-FREE MIGRAINE

     A significant number of patients present with the associated signs and symptoms of a migraine, including nausea, vomiting, diarrhea and visual disturbances, yet they do not have the hallmark headache. These patients may also have significant vertigo (dizziness).

HEMIPLEGIC MIGRAINE

     This patient usually presents with unilateral paralysis, visual disturbances and vertigo prior to the headache, which typically follows some 10 to 90 minutes after the initial physical symptoms appear.

EXERTIONAL HEADACHE

     This is generally associated with physical stress or activity such as running, weight-lifting or aerobic exercising. It may even come on secondary to coughing or sneezing.¹

CLUSTER HEADACHE

     Sometimes known as toxic or histamine headache, a cluster headache is still considered a vascular headache. Most patients describe cluster headaches as very severe and debilitating. The onset of a cluster headache may be gradual, with discomfort over one eye that spreads rapidly to the same side of the face. Typical onset is 2 to 15 minutes to peak intensity and is generally without warning. The pain, which is described as deep within the head, is not pounding in nature, but rather explosive in quality. It is not uncommon for a patient suffering from a cluster headache to say it is "like an ice-pick in my head."

     Duration of a cluster headache is generally 10–45 minutes; however, it can last up to four hours. The cluster headache gets its name from the "clusters" or frequent reoccurring periods in which the headache takes place.⁷

     Many individuals who suffer from cluster headache will experience one or two cluster periods a year. These periods often last two to three months each and seem to be more common in the spring and fall seasons. The headache may occur once to several times a day, generally coming on at the same time each day, i.e., "cluster times."

     Cluster headaches may begin at any time of life, but usually appear sometime in the early 20s to early 40s. They are more commonly associated with men than women. Cluster headache sufferers often have hazel-colored eyes, and are heavy smokers and drinkers.¹ It is interesting to note that although the nicotine in cigarettes causes vascular constriction and alcohol causes vascular dilation, both substances may trigger cluster headaches.

     Unless newly diagnosed, patients with a history of cluster headache will have explored a number of treatment options with their physician in order to find one or a combination of treatments that work best for them. Many of the medications are similar to the treatment options for migraine, and ergotamine preparations; oral analgesics, typically NSAIDs or a narcotic like codeine; corticosteroids, such as prednisone; and antidepressants like lithium have been shown to be very effective. Often, this treatment may be combined with ergotamine.^8–10

     Intranasal lidocaine drops have also been effective in aborting cluster headaches in a large percentage of patients. The administration of lidocaine is believed to be effective because of its anesthetizing properties on nerves. Specifically, it has found success in headaches (migraine and cluster) where the trigeminal nerve acts as a motor pathway for pain, causing headache. The ability of medication to block the terminals of both the trigeminal and glossopharyngeal nerves has been identified as an extremely useful and minimally invasive therapy.⁹

     Not all patients respond to medical intervention for treatment of their cluster headache. To gain control over the headache and become free from its crippling pain, some individuals seek a more invasive, or even surgical, remedy. These interventions range from injections into the trigeminal nerve to use of radio frequency to disrupt nerve function, and, in some instances, cutting the nerve or branch of the nerve to stop the pain impulses.¹

     For EMS providers called to a patient experiencing severe headache, there are some physical presentations that may clue you in to the cluster headache. The patient will describe the pain as starting around or behind one eye, which will be tearing (lacrimation), and the nares on the same side will either be blocked or runny (rhinorrhea). The affected eye will be injected (red), and the soft tissue around the eye will be swollen much of the time. In some individuals, the physical signs are so pronounced that one can literally draw a line down a patient's face and see the signs on one side but not the other. The patient may be pale and diaphoretic, and may complain of scalp or facial tenderness. It is not unusual for these patients to also present with mild bradycardia.¹¹

     Your first impression of a patient experiencing a cluster headache is that this patient is in real distress. The patient may try lowering his head to find a position of comfort; for some, physical exertion may provide relief from the pain. These patients may have a difficult time sitting still for your assessment. Because of the severity of pain, some patients may even verbalize a suicide threat.

     A number of patients respond very favorably to high-concentration oxygen. O₂ delivered via mask at 15 liters/minute for 5–15 minutes may actually prevent the cluster headache from getting worse. The sooner oxygen is started, the greater the chance for breaking the headache.^1,12 Many patients with a history of cluster headache actually carry their own portable oxygen for rapid treatment at the first sign of headache.

     When responding to a patient suffering a cluster headache, an organized approach to assessment is key to not overlooking patient signs or symptoms. Usual treatment includes establishing an IV of normal saline at a TKO rate; oxygen, if not already on the patient; and safe transport, allowing the patient to be in a position of comfort, if possible. Keeping interior lights at a low level and abstaining from using the siren will go a long way toward patient comfort. You can also offer a cold pack and allow the patient to put it where he believes it will help the most. Medication that could be beneficial to the patient would include calcium channel blockers, such as verapamil (Calan) and antiemetics like prochlorperazine (Compazine). Consult with online medical direction, since this is most likely outside your usual EMS system protocols.

HEADACHES IN CHILDREN

     Generally speaking, kids may suffer from the same types of headache as adults. Keep in mind that often, when kids get headaches, there may be something else going on. It is very common for children to have headaches with a fever or as a medication side-effect. Playing outside on a hot summer day and becoming dehydrated may also induce a headache. It is not unusual for children to become nauseated with a headache, but a child who also complains of visual changes, tingling sensations and weakness, or has a decreased level of alertness should be given special consideration and transported without delay.¹³ Again, a thorough assessment should bring this to light for the EMS provider.

SUMMARY

     There are many more causes or conditions that may present as a severe headache, and it is sometimes difficult to get a complete understanding of what the patient is experiencing. Keeping in mind our caregivers' mantra to "do no harm," and keeping all senses in tune to your patient's presentation, you'll go a long way toward making your patient feel better and instilling them with confidence that you care.

References

1. National Institute of Neurological Disorders and Stroke. Headache hope through research. www.ninds.nih.gov/disorders/headache/detail_headache.htm#27483138.

2. Prevalence of Diabetes in the United States, all ages, 2005. https://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#7.

3. Epilepsy and Seizure Statistics, 2005. www.epilepsyfoundation.org/answerplace/statistics.cfm.

4. Asthma Facts, US Environmental Protection Agency. www.epa.gov/iaq/asthma/pdfs/asthma_fact_sheet_en.pdf.

5. Manzoni GC, Torelli P. Headache screening and diagnosis. Neurol Sciences, Oct 2004.

6. www.emedicinehealth.com/migraine_headache/article_em.htm.

7. Mathew NT. Advances in cluster headache. Neurol Clinician, Nov 1990.

8. Dalessio DJ. Scripps Clinic. Cluster headache and cranial neuralgias, Feb. 2003.

9. Menndizabal J. Cluster Headache. www.emedicine.com/neuro/topic70.htm.

10. www.neuroland.com/ha/cluster.htm.

11. Saper JR and staff, Michigan Head-Pain & Neurological Institute. www.mhni.com/faqs_cluster.html.

12. www.emedicinehealth.com/cluster_headache/article_em.htm.

13. Blanda M. Summa Health System. www.emedicine.com/emerg/topic230.ht.

Bibiliography

Lee D. MedicineNet, Migraine. www.medicinenet.com/migraine_headache/article.htm.

National Headache Foundation, Migraine Headache. www.headaches.org/consumer/topicsheets/migraine.html.

Gary Wiemokly, MPH, EMT-P, RN, is EMS chief for the Town of Enfield (CT) Emergency Medical Services.