The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Primary Headache in
Emergency Setting
Surat Tanprawate, MD, MSc(Lond.), FRCP(T)1, 2
1Division

of Neurology, Department of Medicine

2The Northern Neuroscience Centre
Chiang Mai University

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Primary headache in ER

Diagnostic issue for common primary headache

Identify primary headache disorder mimickers (migraine

mimickers, TACs mimickers)

Knowing the unusual presentation of primary headache

(migraine)

Successful management typical primary headache disorder

Typical acute migraine and cluster headache attack

Knowing the other primary headache that may present at ER

Diagnostic issue for primary

headache in ER

Cause of Symptomatic Migraine

Cause
Vascular disorder
CADASIL, MELAS,
aneurysm, AVM, CAA,
carotid dissection, TIA/
Stroke, temporal arteritis
systemic hypertension
Non-vascular disorder
pineal cyst, neoplasm

The Northern Neuroscience Centre

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NNC CMU

Suggestive features
Age of onset > 60
Progressive headache
Sudden onset
Prolonged aura
Atypical aura
(eg.hemiparesis)
New headache features

The Northern Neuroscience Centre

Chiang Mai University

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

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Migraine variant / with red flag signs

Migraine related vertigo

Acephalalgic migraine

Migraine with prolonged aura

Hemiplegic / migraine with brainstem aura

Crash migraine (Evans et al. Headache 2007;Dodick DW JNNP 2002)

Nocturnal migraine(Dexter JD Headache 1975)

New onset migraine in the elderly(Evans et al. Headache

2002;Haan J Cephalalgia 2006)

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Migraine complication that may present in ER
Migrainous infarction

The present attack in a patient with Migraine

with aura is typical of previous attacks except
that one or more aura symptoms persists for
>60 minutes with neuro-imaging demonstrates
ischemic infarction in a relevant area

Migraine trigger seizure

A seizure fulfilling diagnostic criteria for

one type of epileptic attack occurs
during or within 1 h after a migraine aura

Primary headache management

in emergency setting

The Northern Neuroscience Centre

Chiang Mai University

Migraine Emergency

NNC CMU

Character of Migraine at ER

Ideal medication

Attack refractory to usual

treatment (42%)

high efficacy

Severity of attack (13.5%)

rapid onset

Severity of accompanying
symptoms (25%)

low recurrence rate

easy access route (IV)

few adverse event

Aura disturbances (7.2%)

First episode of headache

(4.4%)

Status migrainosus (8.4%)

Rosanna Cerbo et al. J Headache

Pain (2005) 6:287289

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
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

3. Inhibition of impulse transmission

centrally in the TNC
4. Presynaptic blockade of synaptic
transmission between axon
terminals of there peripheral
trigeminovascular neutrons and
cell bodies of there central
counterparts

5-HT1D

5-HT1F

The Northern Neuroscience Centre

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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

The Northern Neuroscience Centre

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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

The Northern Neuroscience Centre

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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)

2. Ability to provide significant headache relief (complete or partial)

Neuroleptics and sumatriptan provide significant headache relief at
various time points after administration
- Neuroleptics (haloperidol, chlorpromazine, prochlorperazine, droperidol) at 60
mins (RR = 2.69)
- Sumatriptan at 60 mins (RR = 3.03)
AHRQ:The Agency for Healthcare Research and Quality

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
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)

4. Ability to prevent recurrence

Dexamethasone plus standard abortive therapy are less likely to
report recurrence of pain or headache up to 72 hours (RR = 0.68;
95% CI, 0.49 to 0.96).

AHRQ:The Agency for Healthcare Research and Quality

The Northern Neuroscience Centre

Chiang Mai University

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

The Northern Neuroscience Centre

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NNC CMU
Dexamethasone
IV in ER setting
14 studies (56%) used IV Dexamethasone

IV Dexamethasone provides a reasonable option for managing resistant,

severe, recurrent or prolonged migraine attacks in the ED
Woldeamanuel TW et al. Cephalalgia 2015, Vol. 35(11) 9961024

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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.

VAS scores at 15 and 30 min of treatment. Changes were

significant at 30 min in all groups (P < 0.000), but the difference
between groups was not significant at either 15 or 30 min.

Cete Y, et al. Cephalalgia 2005; 25:199204

The Northern Neuroscience Centre

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Occipital nerve block(ONB) in acute and transitional
therapy in migraine
Reference

Intervention

Results

Study design

Gawel and Rothbart

97

A single or repeated
GON block(s) using
lidocaine and
methylprednisolone

Caputi and Firetto

27

Repeated GON and SON Headache improvement in

blocks using bupivacaine 85% of subjects for up to 6
months

Retrospective

Bovim and Sand

14

A single GON block with

or without SON block
using lidocaine and
epinephrine

Retrospective

Ashkenazi and Young

19

A single GON block using A significant decrease in

lidocaine and
head pain in 90% of
trianmcinolone, and TTP subjects
using lidocaine

Headache improvement in Retrospective

54% of subjects for up to 6
months

Head pain reduction in 6%

of subjects at 30 minutes

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

Local aesthetics reversibly bind to the voltage-gated Na+ channels,

block Na+ influx, and thus block action potential and nerve conduction

2 cm.below
2 cm.lateral

2% Lidocaine 1.5 cc./side

Levin M. Neurotherapeutics. 2010 Apr;7(2):197-203.

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Occipital nerve block in migraine - a case study
Pt.NO.

Visual analog scale

(VAS)

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

Dollaporn & Surat Chiang Mai Headache Clinic2013

Cochrane review 2009

Hyperbaric oxygen in migraine attack

The Northern Neuroscience Centre

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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

The Northern Neuroscience Centre

Chiang Mai University

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Cluster headache acute therapy
EFNS recommendation (2006)

European Journal of Neurology 2006, 13: 10661077

Knowing the other primary headache that

may present at ER
Hypnic headache
Primary thunderclap headache
Headache associated with sexual activity

The Northern Neuroscience Centre

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Hypnic headache (HH)

Described by Raskin (1988)

Previous terms: curious sleep-related headache

syndrome, alarm clock headache

Secondary hypnic headache case reports: obstructive

sleep apnea, posterior fossa meningioma, pontine
infarct, nocturnal arterial hypertension, pituitary
macroadenoma, transient HH syndrome after lithium
withdrawal
Caminero et al. Cephalalgia 30(9) 11371139

The Northern Neuroscience Centre

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NNC CMU
Clinical findings in patients with hypnic headache (n=96)

Dodick DW et al. Cephalalgia 1998;18:152156.

The Northern Neuroscience Centre

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NNC CMU
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

Liang JF, Wang SJ. Cephalalgia 2014,34(10) 795805

Acute and Preventive treatment options for HH

The Northern Neuroscience Centre

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Primary Headache associated
with sexual activities (HSA)

First described in 1974 (prevalence 1%)

2 types

type 1: Preorgasmic headache-dull ache in the head and

neck with awareness of neck a/r jaw muscle contraction

type 2: Orgasmic headache-sudden severe (explosive)

-> 25% severe pain continue >2 hrs to 24 hrs

SAH need to be excluded in every cases

The Northern Neuroscience Centre

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Management at ED

acute treatment after the onset

short-term prophylaxis

NSAIDs (paracetamol, ASA, diclofenac, ibuprofen) - no

benefit

Indomethacin 25-100 mg given 30-60 min prior to sexual

activity

long-term prophylaxis

Propranolol (60-240 mg), metoprolol, atenolol, ditiazem

Free A, Ever S. Practical Neurology 2005;5:350355

The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Primary thunderclap headache (PTCH)

Thunderclap headache described by Raskin(1986) for sudden

headache caused by cerebral aneurysm

Thunderclap headache: severe head pain of sudden onset,

reaching maximum intensity in <1 min lasting from 1 h to 10 days

Secondary thunderclap headache

SAH, CVST, pituitary apoplexy, SIH, reversibel

vasoconstriction syndrome, myocardial infarction,
pheochromocytoma, hypertensive encephalopathy,
obstructive hydrocephalus, carotid dissection, retroclival
hematoma
Dodick DW. Headache 2002 42:309315

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Management

Usually self limited in 2 months

Acute therapy - no

Preventive therapy - Nimodipine, Gabapentin

Thank you for your

kind attention
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