Evaluation of the headache patient begins with the historical exam. Physical findings of concern associated with the headache include: unequal weakness; generalized malaise and inability to ambulate; fevers; neck stiffness; and unequal pupils. Primary causes for the headache include tension headache, migraine, cluster and caffeine withdrawal, and the secondary causes include infection, subarachnoid hemorrhage (SAH), eye complaints, and tumors. Secondary headache is tending to improve as underlying cause of the headache is treated. This chapter presents a review of the common treatment options for the management of headache in the EMS environment. These include inhaled oxygen, anti-emetics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDS), and analgesics. EMS providers must have a heightened level of concern for the causes of headache requiring emergent treatment. The area of headache evaluation and management in the EMS environment needs further study.

The analysis of many different studies on the characteristics of headaches provides data to help predict the type of cerebrovascular disease according to headache patterns. Lack of headache at onset, sentinel headache, or associated vomiting is predictive of ischemic stroke. A history of throbbing headache is predictive of developing headache during a stroke. A headache preceding the cerebrovascular event (sentinel headache) has been a common occurrence in most studies, reported in up to 60% of patients. The coexistence of headache and stroke encompasses a large spectrum of possibilities, including stroke caused by migraine headache, migraine developing after a stroke, and non-migraine headache occurring in relation to stroke. A higher incidence of patent foramen ovale (PFO) in migraine with aura patients suggests that cardiac microemboli affecting the vertebrobasilar circulation may participate in the migrainous mechanisms of these patients.

The ED physician frequently encounters patients with migraine headache (MH). The ergot alkaloids, available in myriad formulations, are among the oldest drugs used for MH. Clinicians noted that MH pain was often alleviated before the real analgesic was administered by prompting interest in the use of antiemetics as stand-alone therapy. Like the antiemetics, the triptans are useful in myriad benign headache syndromes. Clinical trial evidence from the ED demonstrates sumatriptan's equal efficacy in migraine, probable migraine, and tension-type headaches. Controlled trials demonstrate efficacy of multiple NSAIDs for MH pain. Among those drugs performing better than placebo are aspirin, ibuprofen, tolfenamic acid, diclofenac, and naproxen. Despite their non-specific mechanism of action, opioids are frequently used for MH. Prophylactic medications that may have ED utility in the earliest stages of migraine include the beta-blockers (e.g. metoprolol, propranolol) and the calcium channel blockers.

The typical evaluations of headache include vital signs, palpation of the sinuses, temporomandibular joint and cervical musculature, and auscultation of the carotids in addition to neurological examinations. Although plain films of the sinuses, temporomandibular joint, or cervical spine are occasionally helpful, brain computerized tomography (CT) or magnetic resonance imaging (MRI) are the imaging studies of choice for headache. Subarachnoid hemorrhage (SAH) afflicts nearly 30,000 Americans each year, the majority suffering a ruptured intracranial aneurysm. The primary headache syndromes include: tension-type headache, cluster headache and migraine headache. Given the wide array of newer treatment options for acute migraine, the role of narcotics has become more limited. However, it is compassionate and necessary to treat occasional patients who have failed all reasonable options with potent narcotic analgesics. Most migraine headaches may be aborted with parenteral sumatriptan, dihydroergotamine, or neuroleptic agents.

Migraine headache is an extremely common and temporarily disabling headache disorder. Most studies on migraine prevalence have reported variation by age and gender. Prevalence is generally highest between the ages of 25 and 55, often with a peak in the late 30s and early 40s. Migraine was once considered to be a disease of the affluent. The American Migraine Study showed that migraine prevalence was lower in African-Americans than Asians. Familial aggregation of migraine has long been recognized and genetic studies have generally supported a role for both genetic and environmental risk factors in the etiology of migraine. The heterogeneity of familial hemiplegic migraine (FHM) underscores the likely heterogeneity of the more common types of migraine. Diagnosis of migraine is complicated by the episodic and heterogeneous nature of the illness. Population-based studies demonstrate that migraine is comorbid with depression, anxiety disorders, and manic depressive illness as well as epilepsy.