IM17.10-14 | Headache Emergency Care and Treatment — Summary & Reflection

KEY TAKEAWAYS

Emergency admission indications: thunderclap headache, meningism ± fever, altered consciousness, focal neurological deficit, papilloedema, malignancy/immunosuppression context, hypertensive emergency, status migrainosus (>72 hours).

Acute migraine therapy: mild/moderate → ibuprofen 400–600 mg or naproxen 500 mg + metoclopramide/domperidone; moderate/severe → triptan (sumatriptan 50–100 mg, SC 6 mg if vomiting). Triptan contraindications: IHD, uncontrolled hypertension, CVD, hemiplegic/brainstem aura migraine. MOH: NSAIDs ≥15 days/month, triptans ≥10 days/month for >3 months — treat with detoxification.

Preventive migraine therapy (≥4 attacks/month): propranolol 40–120 mg BD (avoid in asthma, heart block); topiramate 50–100 mg/day (cognitive impairment, teratogenic); amitriptyline 10–75 mg nocte (dry mouth, sedation, QTc). Minimum 3-month trial.

Bacterial meningitis: ceftriaxone 2 g IV q12h + dexamethasone 0.15 mg/kg q6h × 4 days (with first antibiotic dose); add ampicillin for age >60 or immunocompromised (Listeria cover). Duration 5–21 days by organism.

TBM: 2HRZE (2 months) + 10–12HR (10–12 months) = 12–18 months total; dexamethasone (0.3–0.4 mg/kg/day tapering); pyridoxine with isoniazid. Per NTEP, daily dosing, weight-band FDC.

Herpes simplex encephalitis: IV acyclovir 10 mg/kg q8h × 14–21 days — START EMPIRICALLY; do not await HSV PCR.

Counselling: headache diary; trigger avoidance; MOH education (≤10–14 analgesic days/month); red flags for emergency attendance (thunderclap, fever + meningism, focal deficit); preventive therapy adherence (6–8 weeks to effect, 3-month trial).

REFLECT

Return to the opening vignette. Deepa needed SC sumatriptan 6 mg because she could not swallow — oral drugs are not absorbed in the presence of migraine-related gastric stasis, and waiting for her vomiting to settle meant hours of unnecessary suffering. Ramesh needed his sumatriptan stopped immediately — a drug that provides clear therapeutic benefit in uncomplicated migraine becomes a lethal risk in a patient with ischaemic heart disease. And the student in the resus bay needed IV ceftriaxone before the LP, and dexamethasone before or with the ceftriaxone — every minute of delay in both actions was measurable neurological morbidity. What strikes you about these three cases is not that they are unusual — it is that they are entirely routine presentations in any busy outpatient clinic and emergency department. Headache is common. The pharmacological precision required to treat it well is not trivial. And the counselling that prevents medication overuse and teaches patients to recognise red flags is what separates episodic, manageable migraine from the 'nothing works' daily headache that arrives at your clinic months later.