MDM - Tension Headache

[##-year-old male/female] with headache with history and exam consistent with likely tension headache.

Initial consideration in this patient included tension headache, migraine, cluster headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.

Patient presented with headache and a normal neurologic exam without report of preceding trauma.  Headache described as [tightness/pressure] in the [right/left/bilateral temporal/frontal/parietal] head without report of associated [nausea/blurred vision/photophobia], or other features suggestive of migraine headache.  Patient reports recent [decreased caffeine intake/insomnia/stress] suggestive of tension-type headache.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time [in patient meeting none of the Ottawa SAH rules as noted above].  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  No indication for neuroimaging at this time based on normal neurologic exam in patient with headache with features suggestive of tension-type headache.  Patient reported significant improvement with [treatment] prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation
https://rebelem.com/the-ottawa-sah-clinical-decision-rule/

MDM - Migraine Headache

[##]-year-old [male/female] with headache with history and exam consistent with likely migraine.

Initial consideration in this patient included migraine, cluster headache, tension headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.  

Patient presented with headache suggestive of likely migraine based on [headache lasting 4-72 hours with unilateral location, pulsating quality, moderate to severe pain intensity and avoidance of routine physical activity with associated nausea and/or vomiting, photophobia, and phonophobia].  Patient noted to have a normal neurologic exam without report of preceding trauma.  Patient [did/did not] describe associated aura suggestive of typical migraine.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  

Neuroimaging was felt to [not be indicated at this time based on normal neurologic exam in patient with headache with features suggestive of migraine/obtained in this patient due to report of headache that differs in character from prior migraines/other concerning feature(s)].  After discussion of available options for treatment [the patient was given Metoclopramide (Reglan)/Prochlorperazine (Compazine)/Haloperidol (Haldol)/Dexamethasone (Decadron) with Diphenhydramine (Benadryl)/Ketorolac (Toradol)/Acetaminophen (Ofirmev)/a sphenopalantine ganglion (SPG) block/a greater occipital nerve (GON) block].  Patient reported significant improvement with treatment prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation and consideration of possible imaging or referral to Neurology, and the patient demonstrated understanding and agreement.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/
http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Discharge Instructions - Tension Headache

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a tension headache.  A tension type headache tends to cause pressure over both sides of the head in the area of the temples.  It is usually triggered by various stressors.

Symptoms of tension type headaches (TTH) include:

-Pressure or tightness around both sides of the head or neck

-Mild to moderate pain that is steady and does not throb

-Pain is not worsened by activity

-Pain can increase or decrease in severity over the course of the headache

-There may be tenderness in the muscles of the head, neck, or shoulders

People with TTH often feel stress or tension before their headache.  Unlike migraine, tension headaches occur without other symptoms such as nausea, vomiting, sensitivity to lights and sounds, or an aura.  However, some people have symptoms of both tension and migraine headache.

Some people find that their tension headaches are triggered by certain things.  If you can avoid some of these things, you can lower your chances of getting a headache.  You can also keep a "headache calendar."  In the calendar, write down every time you have a headache and what you ate and did before it started.  That way you can find out if there is anything you should avoid eating or doing.  You can also write down what medicine you took and whether or not it helped.

For tension headaches, your doctor might suggest an over-the-counter medicine such as Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin), or Naproxen (Aleve).  There is also a medicine that combines Acetaminophen, Aspirin, and Caffeine (brand name Excedrin).

Return to the Emergency Department for worsening or persistent headache, vision changes, slurred speech, weakness or numbness in the face or extremities, fever, inability to tolerate fluids by mouth despite treatment, or any new or concerning symptoms.