Just A Headache?

What EMS providers need to know about the signs and symptoms of headaches


LEARNING OBJECTIVES

  • Review symptoms of headaches
  • Discuss various headache types
  • Review prehospital treatment for the headache patient

Click here to access a 20-question review test for your training purposes.

     At 1428, your unit is sent to a private residence for a reported possible stroke. Upon arrival, an obviously worried family member takes you to a back room, where you encounter a 33-year-old female lying in a recliner. The room is well kept, and you note the lights are off, with just a bit of sunlight coming through the closed curtains.

     As you introduce yourself and your partner to the patient, you note she is breathing, and her verbal response is coherent and clear. You also see that she is clearly anxious. When you ask how she is feeling, Mary tells you that she awoke from a nap with severe right-sided head pain and she has lost her peripheral vision. "It's gone black," she says. Her vital signs show a strong and regular pulse of 94, an unlabored respiratory rate of 18, and blood pressure of 154/90. You administer the Cincinnati Stroke Scale (CSS) and don't notice any deviation from a normal response. Mary denies allergies to medication, says she uses seasonal allergy medication, and denies specific past medical history.

     You administer O2 at 15 LPM via a non-rebreather mask, establish an IV of normal saline and check her blood glucose, which is 94. As you move the patient by gurney to the ambulance and prepare for transport, she begins to complain of nausea and then vomits. Your transport decision is an emergency facility that has head CT available. You arrive at the hospital after an approximately 25-minute transport, provide your hand-off report to the staff taking over her care, complete your paperwork and check on Mary prior to returning to service.

     Approximately four hours later, you return to the same hospital with another patient. After turning this patient's care over to the staff, you ask about Mary and learn that her CT was read as normal and her diagnosis was acute migraine headache. She was medicated for pain control and discharged to follow up with a neurologist.

     Your initial impression included consideration of a possible stroke, and you are a little surprised to find this was ruled out in light of her visual disturbances and the severity of her headache. A number of headache types may produce or carry associated symptoms that mimic a stroke or other potential diagnosis. It is important to remember that in the prehospital setting, it is nearly impossible to make such a diagnosis, and EMS providers should avoid snap assessments that may lead to treating a patient inappropriately.

HEADACHE TYPES

     Following are some symptoms and patient presentations that are common with different headache types.

TENSION HEADACHE

     This patient typically presents with a chief complaint of head pain described as a tight band around his head that may be heavy or oppressive. In tension headache, the pain is most often described as being on both sides of the head, and there may be some referred pain to the patient's neck.

     Getting a handle on how much head pain a patient is experiencing may be extremely difficult. A good assessment for head pain is to note the patient's activity level. Patients experiencing a tension headache will be able to perform what are known as activities of daily living (ADL), such as getting out of bed, walking around the house, and descending or ascending stairs, without the pain interfering or limiting these activities. It doesn't mean they don't have pain; it is just an indicator of pain severity and that their activity does not increase the pain.

     It is not uncommon for a patient with a severe tension headache to also complain of nausea and vomiting, which often leads to a 9-1-1 call. The patient may have a history of tension headache, but has never experienced nausea or vomiting with it. It is not uncommon for this patient to complain of sensitivity to light (photophobia) or sound (hyperacusis), but not both.

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