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Inpatient Headache (HA)

Lauren Waskowicz


  • Important to distinguish primary and secondary headache

  • “Red flags” for secondary headaches (SNOOPPP): systemic symptoms, Neurologic symptoms, Onset that is sudden (thunderclap), Older age (new headache >40), Progression or evolution in previous headaches, Postural component, Pregnancy

  • Other red flags: preceding trauma, headache awakening pt from sleep, no headache-free intervals, thunderclap headache (maximal intensity develops within 11 minutes or less)


  • Get a good description of where the pain is, when it started, associated symptoms, and assess for “red flag” features listed above

  • If there are any red flag features, imaging and workup are necessary

  • Imaging depends on highest suspicions, but CTA head/neck is appropriate to evaluate for aneurysm, dissection or vasospasm (including neck to consider dissection). If any focal signs, MRI is generally preferred; venous imaging can be beneficial in headaches with features of elevated ICP

  • If no red flag features are present, then workup is not necessary, and focus is on treatment


  • NSAIDs and Tylenol for infrequent headaches, but consistent use (>2-3x/week) runs the risk of rebound headaches

  • Triptans for migraine, but contraindicated in patients with CAD, uncontrolled hypertension, and previous stroke. They must be used within 6 hour of onset

    • There are theoretical concerns of serotonin syndrome when used with SSRI/SNRIs
  • Migraines:

    • “Migraine cocktail”: 1L fluid bolus, 4g Mg, IV Compazine(10mg) OR Phenergan(20mg) with Benadryl (25mg)
    • 2nd line: Depakote 1000 mg IV, Decadron 10mg IV , ± Toradol 30mg IV, Flexeril 10mg PO
  • Cluster headache
    • Triptans, high flow O2 (>10 L), can consider intranasal Lidocaine if no arrhythmia history