Prehospital Academy Lesson 18.7
Neurologic Emergencies: Headaches and other Neurological Complaints
This lesson discusses headaches and other common neurological complaints. While often benign, a headache can be a symptom of a serious underlying neurological emergency. It is crucial for EMTs to maintain a high index of suspicion, conduct a thorough assessment to identify red flag symptoms, and provide appropriate supportive care.
Understanding Headaches
Headaches are one of the most common medical complaints. While most are not life-threatening, some are indicators of critical conditions such as stroke, meningitis, or intracranial hemorrhage. EMTs must be able to differentiate between a benign headache and one that requires immediate medical intervention.
Types of Headaches
There are several types of headaches, each with a different presentation:
Tension Headaches: The most common type, often described as a dull, aching sensation or a "tight band" around the head. They are typically caused by muscle contractions in the head and neck.
Migraine Headaches: Often severe, throbbing headaches, usually on one side of the head. They can be accompanied by nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia). Some migraines are preceded by an aura (visual disturbances).
Cluster Headaches: Intense, burning, or piercing headaches that occur in clusters, often at the same time of day for several weeks. They are typically located behind one eye and can be associated with tearing and nasal congestion on the affected side.
Red Flag Headache Symptoms
EMTs must be vigilant for "red flag" symptoms that suggest a serious underlying cause. A high index of suspicion is warranted for any of the following:
Sudden, Severe Onset: Often described as a "thunderclap headache" or the "worst headache of my life." This can indicate a subarachnoid hemorrhage.
Associated with Fever and Stiff Neck: May indicate meningitis.
Associated with Seizures or Altered Mental Status: Could be a sign of encephalitis, hemorrhage, or a tumor.
Following Trauma: Suggests an intracranial injury such as an epidural or subdural hematoma.
Associated with Focal Neurological Deficits: Such as weakness, numbness, or vision changes, which could indicate a stroke.
Assessment of Headaches
A thorough assessment is key to identifying potentially life-threatening conditions.
Primary Assessment (ABCs): As with any patient, ensure a patent airway, adequate breathing, and circulation.
History (SAMPLE & OPQRST):
Onset: Was the onset gradual or sudden?
Provocation/Palliation: What makes the headache better or worse?
Quality: How does the patient describe the pain (throbbing, sharp, dull)?
Radiation: Does the pain radiate anywhere?
Severity: On a scale of 1-10, how severe is the pain?
Time: When did the headache start, and has it been constant or intermittent?
Ask about associated symptoms like fever, nausea, vomiting, vision changes, or neck stiffness.
Neurological Exam: Assess level of consciousness (AVPU), pupil response, and gross motor function to check for any deficits.
Vital Signs: Pay close attention to blood pressure and temperature.
Management of Headaches
Prehospital management for headaches is primarily supportive and focuses on comfort and transport.
Supportive Care: Maintain the patient's ABCs and provide oxygen if they are hypoxic.
Position of Comfort: Allow the patient to assume a position of comfort.
Environmental Management: For patients with suspected migraines who are sensitive to light and sound, dimming the lights in the ambulance and minimizing noise can provide significant relief.
Rapid Transport: Transport the patient to an appropriate facility, especially if any red flag symptoms are present. Advanced level providers may consider pain management and anti-emetics based on local protocols.
Critical Thinking Questions
A patient describes their headache as the "worst headache of my life." What potential life-threatening condition should you immediately suspect, and what should be your priority for management?
You are assessing a patient with a headache, a fever of 102°F, and nuchal rigidity. What are the primary concerns with this presentation, and how does it influence your transport decision?
A patient with a known history of migraines is experiencing a typical episode with severe throbbing pain and photophobia. What simple, non-pharmacological interventions can you provide to improve their comfort during transport?
Explain the importance of asking about the onset of a headache. How does a "thunderclap" onset differ in clinical significance from a headache that has developed gradually over several hours?
During your assessment of a patient complaining of a headache, you discover they had a minor fall two days ago. Why is this historical information critically important, even if the patient initially dismissed it?