This is the protocol for Headaches:
Headache
Let’s break it down!
Headaches are incredibly common, especially among soldiers. Although you don’t necessarily need to be able to definitively diagnose the specific type they’re suffering from, your ability to identify a headache as primary or secondary will greatly influence your treatment. So here’s a quick rundown of what they are:
Primary Headaches are diagnosed when the headache IS the condition itself and not associated with anything else. In other words, the headache is the problem, not a symptom of something greater. Different organizations have different criteria as to what constitutes this, but generally speaking, there are THREE big ones that we have to know:
- Tension Headache
- Cluster Headache
- Migraine Headache
Secondary Headaches are diagnosed when the headache is occurring BECAUSE of something else. In other words, the headache is only occurring as a symptom of something greater like dehydration, illnesses, etc. There are literally over 150 types of secondary headaches, but here’s a quick list of some of the common causes:
- Caffeine withdrawal ☕️
- Sinus congestion 🤧
- Dehydration 🥤
- Concussions/Head injuries 🤕 (Discussed in a different protocol….)
- Strokes 😵
- Hypertension 😡 (This one’s controversial….)
This 5-minute TedEd video offers an excellent introduction to headaches as a whole. Very entertaining and satisfying to watch 👌
Let’s talk a little bit about the physiology of these primary headaches so that we all have a clear understanding of them 🧐
Tension Headaches
These are the MOST COMMON type of headaches (accounts for almost 90% of all primary headaches!). They typically have to do with the inflammation 🔥 of the muscles around the head, as opposed to what’s inside of your head. When you look at the anatomy of the head, you can easily see why these are typically bilateral and “band-like”.
These muscles can get irritated for any number of reasons, whether it be stress 😱, uncomfortable sleeping positions😴, long drives🚗, or really anything that might cause a contraction of these muscles for an extended period of time. These headaches suck, but none of them should really have a rapid onset or include any severe pain. Neurological symptoms shouldn’t really occur either since it doesn’t involve any deep intracranial nerves.
Cluster Headaches
These are the LEAST COMMON headaches, only affecting 0.1% of the entire population. However, they are oddly specific 🤨. They cause very deep, orbital pain on one side of the head. The physiology isn’t totally clear, but most experts agree that it has to do with irritation or stimulation of the trigeminal nerve. By looking at this diagram, you can see why it causes pain around the eye and even some sinus-like symptoms:
They’re called “cluster” headaches because even though they only last between 15 minutes and a couple of hours, they can occur up to 8 times a day during a “cluster” period, which is anywhere between 2 weeks and 3 months. The excruciating pain accompanied with it also gives it the nickname the “suicide headache” 😨
Migraine Headaches
We’ve all heard of a migraine before, but few medics actually understand the physiology behind it. That’s ok though because neurologists don’t quite understand it either🤷♂️. It used to be thought of as a vascular disorder in which the pain would occur as a result of vasodilation within the brain. But now, it’s characterized more as a neurovascular issue in which both the nerves and vascular structures within the trigeminovascular pathway play a role in creating the painful sensation. As you can see from the diagram, there are a LOT of moving pieces:
Migraine symptoms come in all shapes and sizes, but most experts agree that it’s more likely to be unilateral with moderate/severe pain. Since the nerves are involved, we can expect to see more neurological symptoms like auras, motor weakness, etc. than we can with other types of headaches. Sometimes these symptoms are so severe that migraine patients are often confused with stroke patients. The presence of these kinds of symptoms is more likely to steer you towards a migraine diagnosis as opposed to a tension headache diagnosis. In addition, migraine attacks can also cause a delay in the digestive system called gastric stasis, which may play a role in the presence of nausea/vomiting associated with it 🤢. Lastly, migraine patients often experience photophobia (sensitivity to light 💡, not the fear of it…..👻). A nice, dark room will be their best friend.
Meningitis is no joke 😳. Eventually, it’s going to get it’s very own crash course, so I won’t go into too much detail. But to put simply, it’s an inflammation🔥 of the meninges (3 layers around the brain and spinal cord) that’s caused by a viral, bacterial, or fungal infection. It used to be considered more of pediatric disease, but lately, it’s begun to shift into the adult realm, particularly infecting college students and military recruits. It can be a very lethal disease, especially if it goes unnoticed. The reason why it’s mentioned in the headache protocol is that a headache is typically going to be the #1 complaint 🥇about a meningitis patient. They’ll often say that it’s the “worst headache I’ve ever had in my life” and present with nuchal rigidity (stiffening of the neck). Petechial rash, seizures, and mental status changes are other red flags that should clue you into something greater than a headache, although those might be more late signs. Spotting meningitis can be tricky in the early stages, so always keep your mind on this one when you’re taking care of someone with a severe, rapid onset headache 🧐
Analgesics and anti-emetics are the cornerstones of every quality headache treatment plan🌈. When it comes to primary headaches, this is really all you can do 🤷♂️
For pain management, NSAIDs (Ibuprofen, Aspirin, or Ketorolac) and Acetaminophen are going to be your go-to drugs of choice. Tension headaches will respond particularly well to this given that the headaches are the result of an inflammation of the cranial muscles. For Migraines and Cluster Headaches, they’ll still be useful, but don’t expect to have excellent responses. For these patients, you could attempt to give some opiates for breakthrough pain relief, but understand that this is quickly falling out of practice because it isn’t very effective. You’ll find that some patients with a history of migraines will have a prescription for “triptans” like Sumatriptan, Almotriptan, etc. They work by peripheral neuronal inhibition and inhibition of transmission through second-order neurons of the trigeminocervical complex 🤯, which is thought to be involved with these conditions.
Most of us don’t carry these drugs on us, but if your patients have these drugs with them, let them take it! For Cluster headaches, there aren’t a lot of golden drugs out there, but high-flow O2 has actually been shown in some studies to be effective in pain relief for up to 70% of patients! Who knows why? 🤷♂️
Nausea/Vomiting management is pretty straightforward for us: your choice of Ondansetron (Zofran) or Promethazine (Phenergan). Promethazine seems to be a far more stream-lined antiemetic for headaches, especially migraines. This is probably because it also acts as a sedative, which is useful because most headache sufferers typically want to sleep it off 😴. However, promethazine can cause some nasty side effects like akathisia (very unpleasant restlessness) and dystonic reactions (involuntary movements of the face). Some doctors will add Diphenhydramine (Benadryl) with promethazine to prevent some of these symptoms. But if you’re worried about these things, Ondansetron is always a safe, mostly side-effect-free option 🎉
*Pro Tip: Ever heard of a Migraine Cocktail? Some ER docs have a go-to mix of medications that they give every migraine patient that walks in. There are dozens of different “cocktails”, but one of the traditional ones used to be 60mg of Ketorolac, 25mg of Compazine (similar to promethazine), and 25mg of Diphenhydramine (Benadryl). What will yours be? 🤔
Like we mentioned earlier, these secondary headaches are not problems in themselves, they’re CAUSED by something greater. Therefore, we have to add a little extra treatment in addition to pain and nausea management. Of the hundreds of types, knowing the treatment for these 3 basic ones will serve you well:
- Dehydration: PO hydration or 1L IV bolus of normal saline/lactated ringers 🥤
- Sinus Infection: Decongestants like Pseudoephedrine (60mg PO q4-6hrs), Oxymetazoline (1-2 nasal sprays q12 hours). 🤧
- Caffeine Withdrawal: 100mg of Caffeine (Roughly one cup of coffee!) ☕️
The far majority of headaches are easily managed by a good medic, but always keep an eye out for those red flag symptoms (nuchal rigidity, rapid onset headache, seizures, mental status changes) that might show the nasty meningitis monster ☠️
Good luck out there!
References
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
- The Migraine Cocktail: Emergency Department Management of Headaches
- Mayo Clinic: Headache
- Cleveland Clinic: Headache
- Why every medic should love Deployed Medicine - November 8, 2020
- 3 Areas Where Medics Fall Short - November 7, 2020