HEADACHE is a leading chief complaint among patients seen in the emergency department (ED; Friedman, Serrano, Reed, Diamond, & Lipton, 2009). Many headache sufferers utilize the ED for treatment and management of headache rather than seeking treatment by a primary care provider or headache specialist (Friedman et al., 2009).
Despite the number of visits to the ED among patients who experience headache, the role of the ED in the diagnosis and treatment of primary headache disorders has not been well defined (Friedman et al., 2009). Research has shown that EDs lack clinical guidelines or protocols for the management of primary headaches (Cerbo, Villani, Bruti, Di Stani, & Mostardini, 2005). Successful treatment and diagnosis of primary headache disorders in the ED must take into account the chronicity of headaches as well as incorporate clinical pathways that guide practitioners in selecting appropriate treatment and providing the necessary follow-up care for this patient population. A focal point of current research is to develop treatment strategies that help to decrease the frequency of visits to the ED for treatment of headache as well as prevention of ED admissions through identification and modification of risk factors.
PRIMARY HEADACHE SUBTYPES
Diagnosing a headache disorder is challenging for practitioners given the vast number of headache subtypes. There are four subtypes of primary headache: common migraine, migraine with aura, tension, and cluster headaches (Table 1).
Migraine headaches are the most prevalent type of headache treated in the ED (Cerbo et al., 2005; Friedman et al., 2009). Nearly 23 million people in the United States have been diagnosed with migraine headaches (Wiemokly, 2009). Migraine headaches are caused by cerebral vasospasm and cortical depression and typically occur in women between the ages of 25 and 34 years (Wiemokly, 2009). Patients experiencing a migraine will describe unilateral throbbing pain. Light and noise sensitivity coupled with severe nausea and vomiting are symptoms associated with migraine headaches. The pain that patients experience with a migraine headache is severe enough to interfere with activities of daily living and may cause focal neurologic deficits. There is a wide variety of medications that have been found to effectively treat the pain associated with migraine headaches, such as, serotonin receptor agonists, nonsteroidal anti-inflammatory drugs (NSAIDs), β-blockers, antidepressants, antiepileptics, and calcium channel blockers (Wiemokly, 2009). In the setting of the ED, assessing how the patient's migraine differs from previous migraine exacerbations is essential to provide successful treatment for the patient (Wiemokly, 2009).
MIGRAINE WITH AURA
Patients may or may not describe an aura prior to the onset of the headache, which occurs in the classic presentation of migraine headaches (Wiemokly, 2009). The aura may include visual, sensory, or speech disturbances (International Headache Society [IHS], 2005). Usually the aura develops gradually over a period of several minutes. The migraine headache will occur during the aura or within 60 min after the aura has passed (IHS, 2005).
Patients with episodic tension headaches are less likely than patients with migraine headaches to seek treatment in the ED for headache exacerbation (Friedman et al., 2009). Tension headaches are related to muscle tension in the head and neck and can usually be treated successfully with over-the-counter medication (Wiemokly, 2009). Tension headaches are characterized by bilateral tight or heavy pain, which may radiate to the neck (IHS, 2005; Wiemokly, 2009). Usually the pain is not severe enough to interfere with activities of daily living, but the patient can experience nausea, vomiting, and sensitivity to light and noise (Wiemokly, 2009).
Cluster headaches, which involve the cerebral vasculature, are severe and incapacitating for patients (Wiemokly, 2009). Patients presenting with a cluster headache describe a gradual onset of pain that is characterized as deep and explosive (Wiemokly, 2009). The pain may last for minutes to hours and reoccurs one to several times throughout the day (Wiemokly, 2009). Usually cluster headaches occur in patients between the ages of 20 and 40 years and are more common in men and in patients with hazel eyes, as well as among smokers and heavy drinkers (Wiemokly, 2009). Several treatments have been found to effectively treat cluster headaches and include the use of narcotics, NSAIDs, Lithium, intranasal lidocaine, and high concentrations of oxygen by face mask (Wiemokly, 2009).
HEADACHES IN CHILDREN
Recognizing that children can experience the same type of headache disorders as adults is important. Headaches in children can occur with fever, as a adverse effect of medication, or in cases of dehydration (Wiemokly, 2009). However, the most common cause of headaches in the pediatric population is an upper respiratory infection (Conicella et al., 2007). Among children diagnosed with primary headache disorders, migraine is also the most common (Conicella et al., 2007).
Primary headache disorders are classified according to the IHS, which has developed criteria for the diagnosis of specific primary headache disorders. The IHS classification scale has been found to be useful for long-term treatment regimens but is not as beneficial when patients present with unidentified headaches, such as in the ED (Minor, Smith, Moore, & Biros, 2007). Many ED practitioners do not use the IHS criteria for the diagnosis of headache because nearly one fourth of patients with headache presenting to the ED do not meet the criteria for a diagnosable primary headache disorder or may have an atypical presentation (Friedman et al., 2010; Jung, 2007).
Distinguishing a primary headache disorder from a secondary headache that may be life-threatening is an initial priority. Primary headaches, such as migraine or tension headaches, cause significant discomfort to patients but in general are benign (Dutto et al., 2009). Secondary headaches are related to an underlying pathologic process and are associated with conditions that may potentially cause high morbidity and mortality, such as subarachnoid hemorrhage, increased intracranial pressure, or meningitis (Dutto et al., 2009).
Evaluation of the patient with headache presenting to the ED includes a thorough history as well as physical examination including vital signs and neurologic assessment. The clinician should obtain a focused history and ascertain whether the patient has had headaches in the past, whether and how the headache is different from previous headaches, whether this is an acute onset of headache, and what the patient was doing at the time of headache onset. In particular, the practitioner should evaluate for the presence of fever or hypertension, which may signify that the headache is related a secondary cause. Physical examination should include evaluation for meningeal signs, including nuchal rigidity, Kernig's sign and Brudzinski's sign. The practitioner should provide a comprehensive neurologic examination including Glasgow Coma Scale, assessment of the cranial nerves, motor strength and sensation in bilateral upper and lower extremities, gait, and coordination. Typically, patients with primary headache do not present with focal or general neurologic deficits. The presence of focal or generalized neurologic deficits, acute onset of headache, a headache that the patient describes as the “worst headache of my life,” or the onset of headache during physical exertion, such as during sexual intercourse warrants further evaluation with a computed tomographic (CT) scan of the head or lumbar puncture (Dutto et al., 2009).
Researchers correlate the influx of ED visits among headache sufferers to multiple causes (Table 2). The lack of insurance or a delay in obtaining an appointment with a primary care provider could contribute to the use of the ED for treatment of headache (Friedman et al., 2009). The onset of a headache exacerbation that is refractory to usual treatment, increased severity of headache or a headache that is different in character from usual headaches may be alarming and prompt the patient to seek immediate care at the ED (Friedman et al., 2009). Because of the availability of narcotics in the ED, drug-seeking behavior is a concern among practitioners treating patients with headache in the ED (Friedman et al., 2009).
Furthermore, several variables have been identified as risk factors for the use of the ED among headache sufferers. Interestingly, research has demonstrated that a subpopulation of headache sufferers accounts for the majority of ED visits (Freitag, Kozma, Slaton, Osterhaus, & Barron, 2005). Freitag et al. (2005) found that the majority of patients with a primary headache disorder did not use the ED over the period of 1 year. However, 11.5% of the patients enrolled in the study accounted for more than half of all the visits to the ED for the treatment of headache (Freitag et al., 2005). The study also demonstrates that patients who used the ED for headache described more functional disability related to the severity of the headache and significantly greater decrease quality of life compared to head sufferers who did not use the ED (Freitag et al., 2005). Patients who sought treatment at the ED for headache were deemed less healthy than those who did not, which was revealed by a higher number of annual physician visits (Freitag et al., 2005). In addition, patients who used the ED for treatment of headache were found to have higher levels of depression than headache sufferers who did not use the ED (Freitag et al., 2005). Younger age and female gender was also correlated with increased use of the ED for treatment of headache (Freitag et al., 2005).
The findings from a study conducted by Friedman et al. (2009) parallel the conclusion made by Freitag et al. (2005). The research by Friedman et al. (2009) confirms that most patients with severe headache do not elect to use the ED for treatment of headaches, but rather a minority of patients with headache is responsible for the majority of ED visits among headache sufferers. Only 19% of patients with headache enrolled in the study were responsible for the greater part of all ED visits for management and treatment of headache (Friedman et al., 2009).
Friedman et al. (2009) further examined why patients with headache disorder use the ED rather than a primary care provider or headache specialist. The most common reason cited among patients who visited the ED for treatment of headache was intolerable pain (Friedman et al., 2009). Inability to access a primary care provider as well as the desire to use better or different medications were also among the most common reasons why patients seek treatment for headache at the ED (Friedman et al., 2009). Further analysis demonstrates that ED use for the treatment of headache is more common among patients deemed to have low socioeconomic status (Friedman et al. 2009). Perceived increasing severity of disease, use of prescription medication for headache, consultation, depression, and a tendency to use the ED for nonheadache reasons were described as independent risk factors for the use of the ED among patients with primary headache disorders (Friedman et al., 2009). Education by health care practitioners regarding modification of risk factors may contribute to less annual ED visits for treatment of headache among this patient population.
CURRENT PRACTICE IN THE EMERGENCY DEPARTMENT
The treatment of headache in the ED can become costly when diagnostic testing is involved. When a patient with a headache presents to the ED, most ED practitioners report that they obtain a noncontrast CT scan or perform a lumbar puncture (LP; Perry et al, 2009).
Differentiating between primary and secondary headache initiates the treatment process in the ED. When life-threatening causes of headache have been ruled out, the goal of headache treatment in the ED becomes pain management (Trainor & Minor, 2008). Emergency department practitioners do not seem to select treatment that is based on the patients suspected primary headache subtype and further argue that diagnosing the subtype of primary headache disorder is not a priority in the setting of the ED (Trainor & Minor, 2008). However, an inaccurate diagnosis of the primary headache disorder, or the lack of diagnosis, inhibits the ability of the ED practitioner to effectively treat the patient's headache exacerbation (Sahai-Srivastava, Desai, & Zheng, 2008).
Traditionally, treatment of primary headache in the ED has been centered on the treating physician's preference for medication (Cerbo et al., 2005). Largely, the tendency to base treatment on personal preference can be attributed to the lack of clinical protocols and guidelines for treatment of headache in the ED (Sahai-Srivastava et al., 2008). Despite the volume of patients with a chief complaint of headache presenting to the ED, there is no consensus as to how best treat primary headaches in this setting.
There are a variety of medications that are used for the treatment of headache in the ED, which include dopamine antagonists, antiemetics, opioid analgesics, NSAIDS, and selective serotonin-receptor agonists (Table 3).
Droperidol (Droleptan), prochlorperazine (Compazine), and metroclopramide (Reglan) are dopamine antagonists that have been found to provide pain relief for all primary headache subtypes. Five milligrams of droperidol given intramuscularly has been effective in providing pain relief among primary headache sufferers. However, this medication received a black box warning by the Food and Drug Administration in 2001 because of its profile of adverse effects, which include sedation, akathisia, and cardiac arrhythmias (Hill, Miner, & Martel, 2008). Cardiac monitoring is required when this medication is administered.
Prochlorperazine and metroclopramide are dopamine antagonists that also possess antiemetic properties. The combination of 20 mg of metroclopramide or 10 mg of pro-chlorperazine coupled with 25 mg of diphenhydramine (Benadryl) is particularly effective with migraine headaches (Friedman et al., 2008). Benadryl is administered in conjunction with prochlorperazine or metroclopramide to offset the akathisia that can occur if these medications are given individually. Unlike droperidol, prochlorperazine and metroclopramide also relieve associated nausea and vomiting. Compared to 6 mg of subcutaneous sumatriptan (Imitrex), prochlorperazine has been found to be slightly more efficacious in the treatment of migraine, is less expensive, and has a more rapid onset (Kostic, Gutierrez, Rieg, Moore, & Gendron, 2010).
Opioid analgesics have traditionally been a first-line choice of medications for the treatment of primary headache in the ED (Gupta et al., 2007; Trainor and Minor, 2008). Meperidine is the narcotic that has been used most often to alleviate the pain associated with primary headaches (Friedman et al., 2008). Although international headache societies discourage the use of narcotics for the treatment of headache, opioids continue to be utilized in more than half of all cases of headache exacerbations that are treated in the ED (Friedman et al., 2008, 2010; Sahai-Srivastava et al., 2008; Wasay, Zaki, Khan, & Rehmani, 2006). Opioid analgesics are less efficacious than headache-specific medications, such as sumatriptan. In addition, opioid analgesics are associated with more severe adverse effects including sedation and dizziness and cause higher rates of headache recurrence and chronic migraine. (Friedman et al., 2008; Sahai-Srivastava et al., 2008).
Nonsteriodal Anti-Inflammatory Drugs
Nonsteriodal anti-inflammatory drugs exert their therapeutic effect by suppressing the inflammation that is thought to be involved in the pathogenesis of primary headaches (Meyer, 2009). However, NSAIDs were found to provide the least pain relief for all headache subtypes when compared with other medications (Trainor and Minor, 2008).
Selective Serotonin Agonists
Sumatriptan is a medication that is routinely used in the ED and has shown to provide pain relief for all headache subtypes, with superior relief for patients who experience migraine (Trainor and Minor, 2008). Sumatriptan can be given orally or subcutaneously. Its known adverse effects include coronary artery spasm and chest pain (Minor, Smith, Moore, & Biros, 2007). Six milligrams of sumatriptan given subcutaneously is the effective dose and route for primary headache management in the ED. Sumatriptan should be reserved for patients complaining of severe headache pain or for patients who have a persistent headache that is refractory to other medications (Meyer, 2009).
Although a single medication or combination of medications may provide temporary relief from an acute headache exacerbation, follow-up care is imperative. Research describes that ED practitioners habitually neglect to refer patients with acute headache to a specialist, such as a neurologist, or a primary care provider for appropriate diagnosis and treatment of primary headache disorder (Cerbo et al., 2005).
Friedman et al. (2009) make note of the several advantages for the treatment of headache in the ED including immediate care and access to medications that may not necessarily be available in the primary care setting. The fact that the ED provides care at all hours and 7 days a week make the ED an ideal setting for treatment of headache among patients who are experiencing severe pain.
EMERGING TREATMENT STRATEGIES
The motivation behind emerging treatment strategies for headache in the ED is to decrease the frequency of ED visits for treatment of acute primary headache by preventing headache recurrence, to provide improved pain relief, and to increase the duration of pain relief (Table 4).
Cervical Intramuscular Injections
Mellick, McIlrath, and Mellick (2006) evaluated the effectiveness of lower cervical intramuscular injection with bupivacaine (Marcaine). The injection is performed under sterile condition by the ED practitioner; the bupivacaine is injected 1 to 1.5 in. into the paraspinous muscle bilateral to the spinous process of the sixth or seventh cervical vertebrae (Mellick et al., 2006). The mechanism of action is not well known, and it is unclear whether this type of treatment would constitute a nerve block of the lower cervical dorsal roots (Mellick et al., 2006). However, pain relief is immediate (Mellick et al., 2006). In total, 85.4% of subjects enrolled in the study experienced headache relief after injection with bupivacaine (Mellick et al., 2006). Furthermore, injection with bupivacaine also relieved associated symptoms, such as nausea, vomiting, and sensitivity to light and noise (Mellick et al., 2006). The authors hypothesize that headache relief with this therapy may be related to the sensory dermatomes at the specific level of the injection or because of the calming of the trigeminocervical complex and the central antinocioceptive pathways (Mellick et al., 2006). Unfortunately, the duration of therapeutic effect of this treatment was not evaluated.
Thienobenzodiazepines (Neuroleptic Agents)
Olanzapine (Zyprexa) is a thienobenzodiazepine and neuroleptic agent that has captured the attention of ED practitioners because its mechanism of action is similar to droperidol, yet olanzapine has fewer adverse effects and less extrapyramidal effects than other neuroleptic medications (Hill et al., 2008). Hill et al. (2008) found that the extent of pain relief among patients with primary headache was equal between patients who were treated with droperidol and patients who were treated with olanzapine. In addition, olanzapine was found to alleviate headache-associated nausea (Hill et al., 2008). Therefore, when droperidol is not available for use, olanzapine is a safe and effective alternative for the treatment of primary headache in the ED (Hill et al., 2008).
Magnesium deficiency has been presumed to contribute to the pathogenesis of primary headaches, particularly migraine (Frank, Olson, Shuler, & Gharib, 2004). Research has shown that patients who experience migraine have lower serum magnesium levels during headache exacerbation and during periods without headache (Frank et al., 2004). Resultantly, a treatment strategy for patients with headache has been the administration of magnesium (Frank et al., 2004). Frank et al. (2004) evaluated the effectiveness of intravenous magnesium for pain relief among patients with primary headache presenting to the ED. Alarmingly, 83% of patients who received intravenous magnesium required additional treatment with rescue medications, such as sumatriptan, parenteral narcotics, or NSAIDs (Frank et al., 2004). Furthermore, intravenous magnesium was found to not effectively treat nausea and photophobia (Frank et al., 2004). The authors conclude that intravenous magnesium is not an effective treatment strategy for primary headache in the ED, and because of the high percentage of subjects requiring additional pain medication, further studies involving the use of intravenous magnesium for the treatment of primary headache in the ED is not justified (Frank et al., 2004).
Neurogenic inflammation is thought to contribute to primary headache recurrence (Baden & Hunter, 2006). Baden and Hunter (2006) hypothesized that the intravenous administration of 10-mg dexamethasone (Decadron) prior to ED discharge, after administration of standard therapy, would suppress the inflammation associated with headache recurrence at 48 and 72 hr. Although long-term use of corticosteroids has multiple adverse effects, such as hyperglycemia and Cushing's syndrome, a one-time dose was not found to cause these events in patients (Baden & Hunter, 2006). The study found that only 9.7% of patients who received intravenous dexamethasone experienced headache recurrence at 48 and 72 hr compared to 58.3% headache recurrence in patients who did not receive dexamethasone prior to ED discharge (Baden & Hunter, 2006).
Many medications that are typically used for the treatment of primary headache in the ED have high rates of headache relapse after treatment (Baden & Hunter, 2006). For example, the relapse rate at 48 and 72 hr after administration of sumatriptan is 34%–53% and 87% after administration of ketorolac (Toradol) (Baden & Hunter, 2006). The half-life of dexamethasone is 36–72 hr, which permits its anti-inflammatory mechanism to take effect during peak hours of headache recurrence (Baden & Hunter, 2006). The authors deduce that 10 mg iv of dexamethasone, coupled with standard therapy in the ED, is effective in preventing headache recurrence and should be incorporated into routine management of primary headache in the ED (Baden & Hunter, 2006).
INTRODUCING PRACTICE PROTOCOLS
The literature has emphasized the need for clinical protocols for the treatment and management of acute headache in the ED. When surveyed, 95.7% of ED practitioners would utilize a clinical protocol for the treatment of acute headache in the ED (Perry et al., 2009). The use of clinical protocols for the management of headache in the ED has had positive outcomes.
Dutto et al. (2009) developed a protocol that categorized patients on the basis of clinical presentation (Table 5). The researchers evaluated outcomes in relationship to the implementation of their protocol for treatment of headache in the ED. Patients were divided into three distinct categories: (1) patients with severe headache accompanied by neurologic deficit, vomiting or syncope, or onset of headache after sexual intercourse; (2) recent onset of headache that is persistent or worsening or a patient over the age of 40 years with a first headache episode; and (3) patients with a history of headache who have a headache exacerbation that is different in length and intensity or is refractory to usual treatment (Dutto et al., 2009). Patients who presented in either group 1 or 2 had CT scans of their head; patients in group 1 also had an LP if the CT scan of the head was negative and there was high suspicion of subarachnoid hemorrhage (Dutto et al., 2009). Patients in the third subgroup did not receive CT scans, but had a thorough evaluation to assess whether the patients' presentation was consistent with a migraine (Dutto et al., 2009). If the patient was diagnosed with acute migraine exacerbation, 30 mg of intravenous ketorolac and 10 mg of intravenous metroclopramide were administered (Dutto et al., 2009). Furthermore, if the patient did not have a migraine-type headache, neurologic consultation was ordered (Dutto et al., 2009). After implementation of this protocol, the researchers discovered that hospital admissions decreased by 40% and the need for neurologic consultation decreased by 22% (Dutto et al., 2009).
Many patients seek treatment and pain management for acute headache exacerbations at the ED. Research has identified several risk factors for use of the ED for acute headache as well as described why patients utilize the ED rather than a specialist or primary care practitioner. Treating physicians and advanced practices nurses (APNs) lack clinical guidelines and protocols to guide treatment for acute headache in the ED and are left with the challenge of selecting one or several medications to provide pain management and symptom relief. However, many ED practitioners have failed to recognize the recurring nature of primary headache disorders and have neglected to make appropriate recommendations or referrals for the necessary follow-up care for patients suffering from headache. Resultantly, many patients return to the ED for persistent headache unrelieved by a one-time dose of medication. The addition of an intervention or medication that provides extended pain relief or prevents headache recurrence is essential. Any patient who has a headache severe enough to seek treatment in the ED should be evaluated, or at minimum, referred to a headache specialist, such as a neurologist. Advanced practices nurses should pursue a multidisciplinary approach in the treatment of primary headache disorders in the ED and collaborate with neurologists to provide comprehensive care.
There continues to be a lack of agreement regarding which medication is most effective for treatment of headache when a patient with an acute exacerbation presents to the ED. Certainly, there are a variety of classes of medications to choose from, each with its own risks and benefits. What researchers have agreed upon is that primary headaches in the ED are its own entity and deciphering between migraines versus episodic tension headache versus cluster headache is not an immediate priority, because many medications appear to provide pain relief for multiple types of headache.
The literature has provided a draft for the development of clinical protocols in the ED for acute headache management, and the research has described positive results from the implementation of this clinical guideline. There appears to be agreement on the work-up and diagnosis of headache. However, the guidelines still lack direction for selecting medication for relief of the patients' pain and symptoms. Practitioners need a decision rule to facilitate their choice of treatment.
New clinical protocols for the management of headache in the ED should encourage clinicians to avoid the use of narcotics. An NSAID such as ketorolac 30 mg iv would be the preferred medication to use in the patient with a mild to moderate headache. In the patient with a severe headache, a headache-specific medication such as sumatriptan 6 mg given subcutaneously is ideal. An alternative option would be to prescribe 10 mg of prochlorperazine coupled with 25 mg diphenhydramine administered intravenously. Prior to discharge from the ED, 10 mg of dexamethasone should be given to the patient intravenously to prevent headache recurrence. Neither diagnostic imaging nor hospital admission is necessitated for patients with suspected primary headache exacerbations presenting to the ED. Upon discharge from the ED, the patient should be instructed to follow up with his/her primary care provider as well as referred to an outpatient neurologist or headache specialist for thorough evaluation and preventative treatment.
The fact that a minority of patients are responsible for the majority of ED admissions due to acute headache is concerning. Practitioners should be alarmed when patients return to the ED for treatment of headache and must carefully evaluate the patient's risk factors, particularly depression and socioeconomic status. When a patient continues to return to the ED for management of headache, the patient has not received adequate follow-up care with a primary care provider or with a headache specialist. Patient education about individual risk factors in addition to ensuring that the patient has a referral to a specialist or primary care provider is a requirement to decrease the number of ED admissions for treatment of headache. The need for referral and follow-up cannot be neglected in the setting of a busy ED.
RELEVANCE TO ADVANCED PRACTICE NURSES
Advanced practices nurses in the ED are involved in the care of patients who present to the ED with a headache. Advanced practices nurses have the skill set to rapidly differentiate a patient with an acute benign headache from a patient with secondary headache and possible life-threatening condition. An important role of the APN in the clinical setting is to implement evidence-based practice and contribute to practice improvement and change. Practice protocols and tools to enhance management of patients with headache have been developed by some APNs. Another critical role for the APN in the ED is that of an educator and a case manager. Advanced practices nurses are also involved in the identification of risk factors, screening for depression, evaluation of socioeconomic status, and referral for follow-up care for patients with headache in the ED setting. Advanced practices nurses provide continuous education for patients regarding modification of risk factors, identification of headache triggers, and prevention of headache exacerbation through life-style change.
Research has provided several incites about patients with headache who are treated in the ED. Yet, further study is needed in the area of prevention of headache, modification of risk factors, and medications or treatment that can provide prolonged pain and symptom relief. Clinical guidelines for acute headache may help to decrease hospital admissions and cut the number of CT scans ordered for patients but have not shown to decrease the number of ED admissions for acute headache. Guidelines need to incorporate the use of medication and treatment aside from diagnosis and whether or not the patient should be admitted to the hospital. Additional research concerning the subpopulation of patients contributing to the largest part of ED admissions for headache is necessary. Several new strategies described in the literature that provide prolonged pain relief show great potential and should be introduced into routine practice for treatment of headache in the ED. Ultimately, the most effective immediate treatment an ED clinician can provide for the patient presenting with an exacerbation of a primary headache disorder is appropriate pain management with a nonopioid headache-specific analgesic, thorough patient education, and referral.
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