Protocol for Patients Presenting with Acute …

1 Protocol for Patients Presenting with Acute headache Any male and non-pregnant female adult with Acute headache Counseling Points -reduce/eliminate alcohol Screen danger signs/symptoms: -reduce/eliminate tobacco -vital signs as in triage -any relaxation strategies that -worsening headache over months the patient can do Danger Sign Present: (meditation, closing eyes and - worst headache ever . -evaluation by physician deep, slow breathing in a - headache of maximum severity at -stabilization quiet space, prayer according onset -consider neuroimaging in to patient's religious -age over 50 years KTM and referral; discuss practices). -additional symptoms of systemic with patient their options -the treatments we provide at illness -seizures or any neurological signs the clinic are not changing the -lethargy disease, but help with symptoms -there are minimal -return to clinic if any of the No Danger Sign Present: danger signs or if problem -obtain additional headache history persists Two of: Two of: Five attacks, with one to eight -Unilateral location -Pressing, tightening, or nonpulsatile attacks on any given day -Throbbing character character Severe unilateral, bilateral, -Pain worse with routine -Mild to moderate intensity supraorbital, or temporal pain activity -Bilateral location lasting 15 to 180 minutes -Moderate to severe intensity -Not worse with routine activity PLUS ONE OF: AND one of: Both of.

2 -Lacrimation -Nausea and/or vomiting -No nausea or vomiting -Nasal congestion or -Photophobia and -No photophobia and phonophobia Rhinorrhea phonophobia (but may have one or the other) -Forehead/facial sweating -Ptosis or Miosis -Eyelid edema Migraine: Migraine: Tension Moderate/Severe Mild/moderate headache Cluster headache Acute Treatment -Metoclopramide Chronic Management Acute Treatment 10mg IV, observe for -Paracetamol 500 mg to 1 -oxygen through face mask at one hour, and gram PO QID as needed 5L per minute for 15 minutes reassess; if minimal (dispensed by an outside Chronic Management improvement, have pharmacy) -Counseling physician evaluate -Counseling Adapted from Am Fam Physician 2005;71:717-24 Notes (typically do not need to be printed out at the clinic; just for reference and documentation). Presently, the primary function of this Protocol is to ensure that headache is not indicative of a more easily treatable condition.

3 Eventually, given its high prevalence in the community and clear impact on quality of life, we need to develop a better primary care approach to non-specific LBP that includes more rigorous lifestyle interventions. We have not included verapamil as a treatment for cluster headache here because of its questionable or minimal impact on symptom reduction. Eventually, as our primary care capacity improves and the evidence for treating cluster headaches with calcium channel blockers expands, we should consider adding this treatment onto the present Protocol .