Emergency Medicine

HEADACHE

General Medical Emergencies 103

(iii) Have at least one associated symptom of:

(a) nausea and/or vomiting

(b) photophobia

(c) phonophobia.

2 ‘Classic’ migraine, or migraine with aura, is less common (25–30%
migraineurs). It has similar features to those above, plus a history of at least
two previous attacks that:
(i) Have a typical aura:
(a) fully reversible visual, sensory or speech symptoms (or
mixed), but not motor weakness
(b) visual symptoms can be uni- or bilateral flashing lights,
zig-zag lines (teichopsia), fortification spectra and a central
scotoma, or transient hemianopia
(c) sensory symptoms are unilateral positive or negative
(c) these symptoms develop over 5 min, or each symptom lasts
≥5 min but <60 min.
(ii) Headache precedes, accompanies, or follows the aura within
60 min, although up to 40% can have an aura with no headache, or
(iii) Have a less typical aura (these are all rare):
(a) hemiplegic (sporadic or familial)
(b) basilar (ataxia, vertigo, tinnitus, nystagmus, diplopia, confusion)
(c) ophthalmoplegic.

3 Therefore it is not possible to diagnose a first episode of migraine, without
first excluding a more serious cause such as a subarachnoid haemorrhage,
space-occupying lesion or other intracranial haemorrhage.
(i) Also do not diagnose a ‘migraine’ if the headache is different
from a typical attack, was sudden or precipitate in onset, is more
longer lasting, if the aura is prolonged and or if there is residual
neurology.
(ii) Get senior ED doctor help and arrange investigations including a
CT brain scan.

MANAGEMENT

1 Nurse the patient in a darkened room, give oxygen by face mask and an oral
analgesic such as aspirin 300 mg three tablets, ibuprofen 200 mg two or three
tablets, or paracetamol 500 mg and codeine phosphate 8 mg two tablets.

2 Give an antiemetic with antidopaminergic effects, such as metoclopramide
10–20 mg i.v.

3 Give chlorpromazine 0.1–0.2 mg/kg i.v. if the above fail, with a f luid bolus of
normal saline 10 mL/kg, or

4 Consider a triptan such as sumatriptan 6 mg s.c. for resistant headache:
(i) Side effects of tingling, heat and flushing may occur, or rarely
chest pain and tightness.