WASHINGTON, D.C.—A headache is one of the common presentations in the emergency department. Of course, the vast majority of them are no big deal. Still, they could be deadly, so be vigilant. Just not so vigilant you order unnecessary imaging. But, obviously, don’t skip a scan that could miss a diagnostic clue of dangerous secondary causes. Also, patients need immediate and effective pain relief. Not opioids, though.

Headache management is enough to give emergency physicians, well, a headache.

Physicians are “told don’t miss anything dangerous, but rarely are you going to see something dangerous,” said Matthew Siket, MD, FACEP, presenter of “Stop the Pounding: Update on Headache Assessment and Treatment” Tuesday at ACEP17. “But also don’t over-image. Don’t get CT scans when you don’t have to. That puts us in a difficult spot in the middle. So what we’re left with when we’re stripped of all that, really, is our history and our physical exam. And these aren’t the patients that want you to spend a lot of time talking to them or examining them.”

Dr. Siket, co-director of the emergency center stroke centers at Rhode Island and The Miriam hospitals in Providence, said that emergency physicians are in a “catch-22” conundrum for managing headaches. He calls a list of secondary causes “something to be mindful of and turn to when you think you might be dealing with something dangerous.”

The most common of those include subarachnoid hemorrhage (SAH)—where 70 percent of patients present with a headache—and reversible cerebral vasoconstriction syndrome (RCVS). Other causes include idiopathic intracranial hypertension, tumors and ophthalmologic issues such as temporal arteritis.

One technique Dr. Siket suggests to catch red flags is the SNOOP mnemonic, which stands for Systemic symptoms, Neurologic signs/symptoms, acute Onset, Older patients (>50 years), and Previous headache history.

Dr. Siket also suggests emergency physicians put critical thought into what medications they use to treat headaches. With the ever-growing opioids crisis, Dr. Siket said studies showing some 59 percent of patients still receive opioids means “we can do better.” However, when emergency physicians eschew opioids they instead “use these secondary indication medications that are full of black-box warnings or adverse side effects on their own,” he said. “It puts us in an uncomfortable position.”

Dr. Siket said physicians can use nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, or other options as alternatives. Mostly, he just wants physicians to take the time to think more critically about what they’re prescribing.

“At the end of the day, you’re going to do what makes you feel most comfortable. I get that and think that’s good,” he said. “If you just realize that there’s maybe a better medication than what we’re choosing to use, keep an open mind.”