In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? May 2019;38:93-103. doi:10.1016/j.ijoa.2018.12.006 These include atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL) and propranolol (Inderal, Innopran XL). PDPH Treatment Options Options include topiramate (Topamax, Qudexy XR, others), divalproex sodium (Depakote) and . APPGPHD. 2000;55(6):754-762. When a second EBP is performed, there is no evidence on the optimum time interval between the first and second EBP.11 A second EBP may be performed once other causes of headache have been excluded. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. -, Evers S, Fischera M, May A, et al. Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. 1 Epidural analgesia is commonly used to alleviate labor pain with a reported rate of over 50% at many institutions in the United States and over 85% in tertiary care labor and delivery centers with 24-hour obstetric . Disclaimer, National Library of Medicine Treatment of obstetric post-dural puncutre headache: Executive summary of recommendations. Cullen S. Treatment of post spinal headache. For migraine, relaxation training with or without thermal biofeedback, cognitive behavior therapy were strongly recommended by the U.S. Headache Consortium based on evidence from consistent findings in randomized controlled trials. European guidelines for TTH recommend electromyographic biofeedback based on a meta-analysis of 53 studies.47 Cognitive behavior therapy, relaxation training, physical therapy, and acupuncture were given lower-grade recommendations because of lack of conclusive evidence of effectiveness.47 Patient adherence is a major barrier to behavioral treatments. Neck pain is common, and autonomic and vasomotor symptoms such as rhinorrhea, nasal stuffiness, and vasomotor instability are reported.35,36 Patients with MOH often have sleep disturbances and psychiatric disorders, especially depression, anxiety, and obsessive-compulsive disorder. See this image and copyright information in PMC. Read More Randolph Evans, MD, FAHS spoke to us about the significance of the recently updated guidelines for neuroimaging in migraine for patients with headache. Accidental dural puncture in obstetric patients and long term symptoms. Guidelines recommend magnetic resonance imaging with and without contrast in patients with trigeminal autonomic cephalalgias (e.g., cluster headache, paroxysmal hemicrania, hemicrania continua, short-lasting neuralgiform headache), headaches with new features or neurologic deficits, or suspected intracranial abnormality.3032 The American College of Radiology recommendations can help guide imaging for various headache presentations, headaches in specific locations (e.g., base of skull, orbit, sinuses), and investigation of specific conditions, and imaging in older adults, pregnant women, and patients with cancer or other immunocompromising condition.32, Decisions about imaging in patients with increasingly frequent migraine or TTH are challenging.1821,24,3032 U.S. headache guidelines recommend magnetic resonance imaging with and without contrast for patients with progressively worsening headaches over weeks to months because of the remote possibility of subdural hematoma, hydrocephalus, tumor, or another progressive intracranial lesion.18 Nevertheless, without neurologic findings, relevant results from neuroimaging are reported in less than 1% of patients who have frequent episodic migraine.23 Other imaging modalities such as positron emission tomography, single-photon emission computed tomography, electroencephalography, and transcranial Doppler ultrasonography are not recommended in patients with frequent headaches.31, Serious pathologic conditions are uncommon causes of frequent headaches, but they must be considered, even in patients with confirmed primary headaches. The major effect of an EBP appears to be within a few segments of the site of injection. Medication overuse headache should be suspected in patients with frequent headaches. Br J Anaesth. Bookshelf Regularly scheduled follow-up is necessary to monitor the patient's headache pattern and make adjustments to the management plan. -, Steiner TJ, Stovner LJ, Katsarava Z, et al. Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients. Minerva Anestesiol. A clear and detailed history is often overlooked in order to expedite obtaining CT scans. Epub 2021 Feb 12. This Danish study of people with probable medication-overuse headache (175 patients) compared the frequency of headache before and after complete drug withdrawal and then after drug management in the clinic. Anesthesiology. Blood should be injected immediately into the epidural space through the epidural needle. Blood patches placed after an initial observation period of greater than 24 hours have a higher success rate approaching 93% after one EBP and 97% after a second EBP. It is usually accompanied by neck stiffness and/or subjective hearing symptoms. Anaesthesia. A survey of recognition and management. The history should cover the patient's typical headaches as well as recent changes. Prior to a third TEBP, further investigation including a neurological consult needs to be considered. CDC officials say that . current evidence-based treatment guidelines for primary headache (ICHD-3, Brown, 2014). Based on lower-quality studies, other factors such as higher patient expectations, older age, older age at onset, headache frequency and intensity, BMI, disability scores, and unemployment are inconsistently predictive of treatment response.56. Goldszmidt E, Kern R, Chaput A, Macarthur A. Expert groups list different red flag warning features. Conservative management in the form of supportive therapy includes bed rest, rehydration, abdominal binders, oral caffeine, and analgesics (nonsteroidal anti-inflammatory drugs, aspirin, acetaminophen, and oral opioids e.g., oxycodone) for the first 24-48 hours and consideration of a therapeutic epidural blood patch (EBP) if conservative management fails (PDPH symptoms not getting better or progressively worse).3, 24 Supportive therapy including rehydration and analgesics may control the symptoms but usually do not provide complete relief. Dec 2004;70(12):823-30. Jeskins GD, Moore PA, Cooper GM, Lewis M. Long-term morbidity following dural puncture in an obstetric population. Patients with frequent headaches require both prophylactic and acute pharmacologic treatment.1821 Evidence-based reviews and guidelines provide a basis for selecting medications for individual patients (Table 5).20,4453 Considerations include effectiveness, pharmacokinetics, medical history, coexisting conditions, adherence, tolerance of adverse effects, cost and insurance considerations, and patient beliefs about the selected agent.21 Patients with a history of MOH with one agent should be prescribed an alternative agent with a lower risk of overuse. The guideline's main focus is primary headache disorders (eg, migraine, tension-type, and cluster headache) and medication- doi:10.1371/journal.pone.0180504 Physical Examination. Copyright 2020 by the American Academy of Family Physicians. Guidelines stress that treatment should be individualized, incorporating patient education, supportive resources, and nonpharmacologic therapies, especially in patients with associated stress and chronic pain conditions. New onset of headache in a patient with history of cancer 5. Committee of Origin: Obstetric Anesthesia Oskoui M, Pringsheim T, Holler-Managan Y, Potrebic S, Billinghurst L, Gloss D, Hershey AD, Licking N, Sowell M, Victorio MC, Gersz EM, Leininger E, Zanitsch H, Yonker M, Mack K. (2019) Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of . If headache is more significant such that activities of daily life and caring for the baby are compromised, an EBP should be considered.11 Expert Rev Neurother. in an analysis of 43 case reports noted that not all patients had permanent resolution of cranial nerve symptoms.29 Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis. The block can be repeated about every 3months. Tepper SJ, Dahlof CG, Dowson A, et al. Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Headache. Guglielminotti J, Landau R, Li G. Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study. 23. The 3rd edition was published in 2010 by the committee chaired by Ann McGregor with Paul Davies and Timothy Steiner being the other members. EBP was more often used in patients with greater initial headache intensity.28 28. 2. Other agents used with insufficient evidence include aminophylline, theophylline, adrenocorticotropic hormone (ACTH), desmopressin (DDAVP), hydrocortisone, dexamethasone, methylprednisolone, triptans, gabapentinoids, methylergonovine, ondansetron, mannitol, and neostigmine and atropine in the treatment of obstetric PDPH.24-26 Quality reporting offers benefits beyond simply satisfying federal requirements. The differential diagnosis of headache in the parturient is presented in PDPH diagnosis above. The future of pain management looks bright. Complete or partial relief may be seen in 5080%.24, 30, 31 Up to 20% of women receive little or no relief from an EBP, even if repeated.11 There is currently no evidence that imaging is needed before performing an EBP in the setting of UDP with classic symptoms.11, 24 If the character of the headache changes, or when associated with focal neurological signs, then imaging would be indicated prior to performing an EBP. Fayyaz Ahmed chairs the committee for the next BASH guidelines due to come out in 2016 with Anish Bahra, Stuart Weatherby and Alok Tyagi being the other members. Bed rest, supine posture, and abdominal binders may have no benefit or are impractical in the setting of a parturient caring for a newborn, and prolonged bed rest is not recommended as it may increase the risk of thromboembolic complications.25 The bibliographies of relevant articles were reviewed to identify any primary sources missed in the original searches. Copyright 2022 American Academy of Family Physicians. A full assessment to clarify headache frequency, type, and severity takes time, but it is an investment in successful management and may avoid multiple patient visits and requests for medication (Table 2).1821 Every effort should be made to accurately diagnose each headache using criteria from the International Headache Society (eTables A through E) that define different primary (e.g., migraine, TTH, cluster headaches) and secondary headaches (e.g., those due to trauma, vascular malformations, infection, or cerebrospinal fluid pressure disorders). Biochemical, metabolic, and other changes induced by frequent headaches and/or medication are thought to cause central sensitization and neuronal dysfunction that results in inappropriate response to innocuous stimuli, lowered thresholds to trigger pain response, exaggerated response to stimuli, and persistence of pain after removal of inciting factors.14 Together, these changes result in increasingly frequentand often dailyheadache and related symptoms. More than 80% of those with confirmed migraine also have TTH, and patients with any primary headache may develop superimposed secondary headaches.28. This can continue for several days but severity usually decreases over a few days, with resolution for most women by four weeks. Before initiating a management plan, the clinical features should be reviewed to verify the probable headache diagnosis, confirm the absence of significant underlying conditions, and identify comorbidities that could complicate management. The proposed mechanism regarding the formation of an intracranial subdural hematoma after UDP is from decreased intracranial pressure placing traction on the bridging veins between the dura and arachnoid, resulting in their tearing and subsequent hematoma formation.16 Blood injected during an EBP spreads predominantly cranially. Headache management . Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. 21. In studies, migraine was the correct diagnosis in 82% of patients previously diagnosed with nonmigraine headaches and in 88% of patients diagnosed with sinus headaches.26,27 Patients often describe more than one type of headache. Nov 2005;52(9):971-7. doi:10.1007/BF03022061 38. The guideline's main focus is primary headache disorders (eg, migraine, tension-type, and cluster headache) and medication-overuse headache. Women receiving caffeine therapy should have their intake of caffeinated drinks monitored and the recommended daily dose should not be exceeded.25 It should be noted the effects of caffeine do not change the underlying course; it is only for short term symptomatic treatment. The estimated mean critical dose and duration of use for triptans are 18 doses per month and 1.7 years, compared with 114 doses per month and 4.8 years for simple analgesics.37 Although not recommended and less commonly used for headache, opioids present the greatest risk of MOH and the most difficult type to treat.35,36, MOH has no classic features. After 6 weeks, chronic headache (35%), backache (58%), and neckache (14%) sequelae persist in the obstetrical population after UDP.3 When parturients are considering labor epidural analgesia, long-term sequelae should be discussed in the informed consent decision-making process. Addressing medication overuse may be the most important intervention for increasingly frequent headaches. It is unclear if these are risk factors or comorbidities, or if they share etiologies with chronic headaches. Migraine prophylaxis Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ. The 2016 guidelines focused almost exclusively on chronic pain. Between the initial visit (before withdrawal) and discharge from clinic post-withdrawal, there was a mean reduction in headache frequency across the cohort of 46% (p<0.0001). Guidelines and expert recommendations from the American Academy of Neurology, Institute for Clinical Systems Improvement, Scottish Intercollegiate Guidelines Network, American Headache Society, U.S. Headache Consortium, and European Federation of Neurologic Societies were also searched. During headache, at least 1 of the following: Not better accounted for by another ICHD-3 diagnosis, Headache (migraine or tension-type) on 15 days per month for > 3 months, and fulfilling criteria B and C. At least 5 attacks fulfilling criteria B to D for acute migraine and/or both of the following: At least 1 of the following fully reversible aura symptoms: At least 1 aura symptom spreads gradually over 5 minutes, At least 2 aura symptoms occur in succession, The aura is accompanied or followed within 60 minutes by headache. Regular scheduled follow-up is important to monitor progress. This site needs JavaScript to work properly. Each year, 3% to 4% of patients with episodic migraine or tension-type headaches (TTH) escalate to chronic forms.5,6. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. The .gov means its official. Prophylactic Epidural Blood Patch (PEBP) However, in severe obstetric PDPH, an EBP within 48 hours of dural puncture may be considered for symptom control, although it may need to be repeated.11 Severity of symptoms should dictate the timing of the EBP. Key Points, References: 4. Do not perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings. In cases of partial or no relief, a second EBP may be performed after consideration of other causes of headache.11 Studies in vitro have shown both lidocaine and CSF have a detrimental effect on coagulation.11, 32, 33 Increasing concentrations of lidocaine cause hypocoagulability and fibrinolysis32 whilst CSF has both procoagulant and clot destabilizing effects.11, 33 EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. Anesthesiology. Patients who suffer from chronic pain and struggle to get their medications are reacting to new federal opioid prescription guidelines. Prevalence of cluster headache in Germany: results of the epidemiological DMKG study. Headache frequency after medication withdrawal in medication-overuse headache. JAMA Neurol. Headaches are of variable quality, intensity, and location. Following discharge from the hospital, all women who experience a recognized dural puncture with an epidural needle or have a PDPH diagnosed require follow-up, regardless of whether an EBP is performed.25 Follow-up should occur on a regular basis until symptoms resolve. At least 1 of the following, ipsilateral to the pain: Either conjunctival injection and lacrimation (in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) or conjunctival injection or lacrimation (in short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms), Attacks fulfilling criteria A to D for episodic short-lasting unilateral neuralgiform headache, Unilateral headache fulfilling criteria B to D, Present for > 3 months, with exacerbations of moderate or greater intensity, Restlessness or agitation, or aggravation of the pain by movement, Responds absolutely to therapeutic doses of indomethacin (150 to 225 mg per day), Headache fulfilling criteria A to E for remitting hemicrania continua, Daily and continuous for 1 year without remission periods of 24 hours, At least 2 episodes fulfilling criteria B to D, Brought on by and occurring only in association with coughing, straining, and/or other Valsalva maneuver, Begins moments after the stimulus and reaches peak intensity almost immediately, At least 2 episodes of headache fulfilling criteria B to D, Brought on by and occurring within 1 hour during sustained external pressure (compression or traction) of the forehead or scalp, Maximal intensity at the site of external pressure, Resolving within 1 hour after external pressure is relieved, At least 2 headache episodes fulfilling criteria B and C, Brought on by and occurring only during or after strenuous physical exercise, Pain occurring spontaneously as a single stab or series of stabs and fulfilling criteria B and C, Stabs recur with irregular frequency, from 1 to many per day, At least 2 episodes of pain in the head and/or neck fulfilling criteria B to D, Brought on by and occurring only during sexual activity, Increasing intensity with increasing sexual excitement, Abrupt explosive intensity just before or with orgasm, Lasting 1 minute to 24 hours with severe intensity or up to 72 hours with mild intensity, Continuous or intermittent pain fulfilling criterion B. An epidural bolus administration of these agents may improve symptoms, but the effect is only transient.24 Headache is a frequent presentation to the Emergency Department. The injection sites (A and B; one to each GON) are identified as being at the proximal third of the distance between a hypothetical line from the occipital protruberance to the mastoid process. 10 yo: sumatriptan intranasally into one nostril 10-20 mg, can be repeated once after at least 2 hours if headache recurs (max 2 doses in 24 hours) limit use to 2-3 times a week to minimise medication overuse headache. Torelli P, Campana V, Cervellin G, Manzoni GC. All Rights Reserved. New onset of headache in a patient with history of HIV infection 6. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. In cases where an EBP has no effect on headache, or if the diagnosis of obstetric PDPH is less certain, or the nature of headache has changed, discussion with other specialties including obstetrics, neurology and neuroradiology should take place before a second EBP is performed. Neurol Sci. Jul 2001;10(3):172-6. doi:10.1054/ijoa.2000.0826 Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study. (Approved by the ASA House of Delegates on October 13, 2021), Download PDF The Primary Care Management of Headache Update in Progress The guideline describes the critical decision points in the Management of Headache provides clear and comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DoD and VA Health Care systems. Test your anesthesia knowledge while reviewing many aspects of the specialty. Patients who develop chronic migraine typically report progressively frequent bilateral frontotemporal TTH-type symptoms with superimposed full-blown migraine attacks. The values represent mean reduction in headache days per month with median and range in brackets. At least 1 of the following, ipsilateral to the headache: Occurring from every other day up to 8 times per day, At least 2 cluster periods lasting from 7 days to 1 year(untreated) and separated by pain-free remission periods of 3 months, Attacks fulfilling criteria A to D for episodic cluster headache, Occurring for 1 year without a remission period, or with remissions lasting < 3 months, At least 20 attacks fulfilling criteria B to E, Severe unilateral orbital, supraorbital, or temporal pain lasting 2 to 30 minutes, Prevented absolutely with therapeutic doses of indomethacin (150 to 225 mg per day), At least 2 bouts lasting 7 days to 1 year (untreated) and separated by pain-free remission periods of 3 months, Attacks fulfilling criteria A to E for paroxysmal hemicrania, Occurring 1 year without a remission period, or with remissions lasting < 3 months, At least 20 attacks fulfilling criteria B to D, Moderate or severe unilateral pain with orbital, supraorbital, temporal, or other trigeminal distribution, lasting 1 second to 10 minutes and occurring as single stabs, series of stabs, or in a sawtooth pattern. 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