Headache is a generalized term given to any pain in the region of the head above eye level.  Pain from headaches can be acute or chronic, generalized or localized, and can range from mild to severe.  The pain may occur on one or both sides of the head, be isolated to a single location, or extend as a band across the skull.  Paramedic assessment of a patient with a headache should include a detailed history followed by a thorough general and neurological examination.  The underlying cause of the pain cannot be diagnosed in the prehospital setting, and transport to hospital is usually required.

• Acetaminophen is an effective first-line analgesic for managing headaches in the prehospital environment
• Nitrous oxide is considered safe and may be effective for managing headache
• Treat nausea and vomiting as required
• Paramedics are not to administer acetylsalicylic acid for headache
• Opioids are of limited benefit in the treatment of migraine.  MORPHine may not be effective and may be associated with delayed recovery.  FentaNYL should only be used to treat severe headache where other measures have failed, and where transport to the treating facility is prolonged.

• Severe dehydration may cause headaches.  IV fluid replacement may be beneficial in these cases.
• Analgesia may not be effective in patients who suffer from previously diagnosed cluster headaches.  High flow oxygen may be beneficial in these cases.

Headache management depends upon in-hospital diagnosis; this cannot take place in the prehospital environment.  Paramedics must provide interim symptom relief until a definitive diagnosis can be made and appropriate management plan developed.  Patients who suffer from migraine or chronic headaches may have a pre-defined treatment plan, and will seek care only when that plan has failed, or the presentation of the headache is new or unusual. 

• The common types of headache include:
  • Vascular
    • Migraines and cluster headaches
    • Can last from minutes to days
    • Characterized by intense/throbbing pain, photosensitivity, nausea, vomiting, and sweating
    • Sudden onset/most severe ever headache (thunderclap) may indicate sub-arachnoid hemorrhage
  • Tension
    • Often starts in the morning as mild and worsens throughout the day
    • Characterized by a dull, achy pain
  • Organic
    • Less common
    • Caused by tumours, infection, or other diseases of the brain
  • Headaches can be a minor inconvenience or may be debilitating.  Occasionally a serious medical emergency may present with headache as a symptom. These include:
    • Subarachnoid hemoorage
      • Sudden onset, severe, instantaneously peaking headache (a “thunderclap” headache)
    • Hemorrhagic strokes
      • Onset of a sudden and severe headache
    • Other vascular eitiologies:
      • Giant cell arteritis, carotid or vertebral artery dissection, venous thrombosis
    • Meningitis
      • Continuous throbbing headache (usually in occiput) with sudden onset of fever, nausea, vomiting, confusion, and stiff neck
      • Frequently associated with a rash which may be maculopapular petechial or urticarial
      • A decreased headache secondary to the administration of metoclopramide is not diagnostic in nature.  Do not make further treatment or transport decisions based solely on a response to the medication
      • Paramedics should use droplet precautions if meningitis is suspected
    • Acute angle-closure glaucoma
      • Headache with severe pain to ipsilateral eye with associated visual changes, or visual loss
    • Carbon monoxide toxicity

Headache and Migraine

1. Alberta Health Services. AHS Medical Control Protocols. 2020. [Link]
2. Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link]
3. Queensland Ambulance Service. Clinical practice guidelines: Neurological/headache. 2017. [Link]