Emergency Medicine

HEADACHE

102 General Medical Emergencies

3 Examine for focal neurological signs. Seizures and coma may develop later.

(i) Look for papilloedema, retinal haemorrhages, exudates and

cotton-wool spots on funduscopy (grade IV retinal changes).

4 Gain i.v. access and send blood for FBC, ELFTs, blood sugar and cardiac

biomarker such as troponin if there are chest pains or ECG changes. Attach a

cardiac monitor and pulse oximeter to the patient.

5 Perform an ECG and request a CXR.

6 Check an MSU for proteinuria and send it for microscopy to look for

evidence of renal disease, with casts or abnormal urinary red blood cells

(>70% dysmorphic).

(i) Perform a urinary -human chorionic gonadotrophin (hCG)

pregnancy test (qualitative and immediate) or send blood

(quantitative but takes time).

7 Arrange an urgent CT brain scan.

MANAGEMENT

1 Give the patient oxygen, and aim for an oxygen saturation above 94%.

2 Get senior ED doctor help and ta ke expert adv ice.

(i) Aim to reduce mean arterial pressure (MAP) initially by no more

than 25%, or aim for a diastolic BP of 100–110 mmHg within the

first 24 h.

(ii) Use oral treatment with labetalol 100 mg, atenolol 100 mg or

long-acting nifedipine 20–30 mg.

(iii) Avoid an i.v. agent such as sodium nitroprusside 0.25–10 g/

kg per min i.v., unless admitted to ICU with intra-arterial blood

pressure monitoring in place.

3 Refer the patient to the medical team for blood pressure control and to

observe for the complications of heart failure, aortic dissection, intracranial

haemorrhage and renal impairment (cause or effect).

Migraine

DIAGNOSIS

1 ‘Common’ migraine or migraine without aura (66–75% migraineurs). This is

diagnosed by a history of at least five previous attacks that:

(i) Last 4–72 h if untreated.

(ii) Have at least two of the following headache characteristics:

(a) unilateral

(b) pulsating or throbbing

(c) moderate to severe

(d) aggravated by movement.