General Approach To Headache:





  1. Must differentiate potentially life-threatening conditions from benign primary HA


  1. Admit all pts with
  2. ICU admission if
  3. Neurology consultation for refractory headaches


Type Comments Treatment
Migraine - unilateral but they are usually pulsatile,
- associated with nausea and vomiting
-  photophobia and phonophobia
Cluster - Male
- severe unilateral pain that lasts from 15 minutes to 3 hours
- extremely sharp, continuous, and incapacitating
- Headaches are associated with at least one of the following ipsilateral signs:
  conjunctival injection
  nasal congestion

  ptosis, eye edema, and forehead and facial sweating
- Sumatriptan : 6 mg subcutaneously as a single dose, may repeat at least one hour after initial dose if required, maximum 12 mg/day
- Oxygen
- Sumatriptan nasal : 5-20 mg in one nostril as a single dose, may repeat at least 2 hours after initial dose if required, maximum 40 mg/day
- zolmitriptan : 2.5 to 5 mg orally as a single dose, may repeat at least 2 hours after initial dose if required, maximum 10 mg/day

- Dihydroergotamine: 0.5-1mg SQ/IM, max: 2mg/day and 6mg/wk

Pt with CVA:
- lidocaine : 1 mL of a 10% lidocaine solution placed with a cotton swab intranasally (ipsilaterally/bilaterally) for 5 minutes
Tension -  Band-like  
Temporal Arteritis - older adults  
Trigeminal Neuralgia    
Tumor Headache    
Medication overuse headache - diffuse, bilateral, almost daily headaches
- People who are overusing medications, and they tend to get worse with physical or mental exertion
Paroxysmal hemicrania - Women
- Present similar to cluster headache but shorter duration.
Subarachnoid Hemorrhage    
Systemic Disease    


Critical Secondary Causes  Reversible Secondary Causes 
Vascular conditions Non–central nervous system infections
  Subarachnoid hemorrhage   Focal
  Intraparenchymal hemorrhage   Systemic
  Epidural hematoma   Sinus
  Subdural hematoma   Odontogenic
  Stroke   Otic
  Cavernous/venous sinus thrombosis Drug-related causes
  Arteriovenous malformation   Long-term analgesic use (medication overuse)
  Temporal arteritis
  Carotid or vertebral artery dissection   Monosodium glutamate
Central nervous system infection Miscellaneous causes
  Meningitis   Post–lumbar puncture
  Encephalitis   Hypertensive emergency
  Cerebral abscess Primary Headache Syndromes 
Tumor Migraine
Pseudotumor cerebri Tension
Ophthalmic conditions Cluster
  Optic neuritis  
Drug-related causes  
  Nitrates and nitrites  
  Monoamine oxidase inhibitors  
  Alcohol withdrawal  
  Carbon monoxide poisoning  
Endocrine conditions  
Metabolic conditions  
  High-altitude cerebral edema