HEADACHE100 General Medical Emergencies
MANAGEMENT
1 Give the patient oxygen and nurse head upwards. Aim for an oxygen satura-
tion above 94%.
2 Give midazolam 0.05–0.1 mg/kg up to 10 mg i.v., or diazepam 0.1–0.2 mg/kg
up to 20 mg i.v., or lora zepa m 0.07 mg /kg up to 4 mg i.v. for seizures or severe
agitation.
3 Give paracetamol 500 mg and codeine phosphate 8 mg two tablets orally or
rarely morphine 2.5–5 mg i.v. for pain relief, with an antiemetic such as
metoclopramide 10 mg i.v.
4 Arrange a CT head scan urgent ly to conf irm t he diagnosis.
(i) CT scan is up to 98% sensitive in the first 12 h, but drops to 50%
by day 7.
5 Proceed to perform a lumbar puncture if the CT brain scan is negative or
unavailable, provided that 8–10 h have passed since headache onset and
there are no focal neurological signs or papilloedema.
(i) Always request xanthochromia studies by spectrophotometry
of the CSF to differentiate a traumatic tap (absent) from a true
subarachnoid haemorrhage (positive).
6 Refer the patient to ICU for admission, or to a neurosurgical unit.
(i) Seek specialist consultation and commence nimodipine 60 mg
orally 4-hourly or an infusion at 1 mg/h if comatose, increased to
2 mg/h after 2 h if the blood pressure is stable, when the diagnosis
is confirmed.Space-occupying lesion
DIAGNOSIS
1 Causes include an intracranial haematoma, cerebral tumour, or cerebral
abscess.
2 The headaches become progressively more frequent and severe, worse in the
mornings and exacerbated by coughing, bending or straining.
3 Vomiting without nausea occurs, and focal neurological signs develop,
ranging from subtle personality changes, ataxia, and visual problems to
cranial nerve palsies, hemiparesis and seizures.
4 Papilloedema may be seen, with loss of venous pulsation and blurring of
the disc margin with filling in of the optic cup as the earliest signs on
funduscopy.
5 Perform a CXR to look for a primary tumour and arrange an immediate CT
head scan.