Migraine Headache or Something More – Determining the Cause of Your Severe Head Pain

Headache is a very tricky area in medicine, both from a doctor’s perspective and a patient’s perspective. 

That is why it is very challenging to advise rules of thumb for the general public – the devil often lies in the details of each specific patient. 

Studies have suggested that more than 80% of headaches are benign, meaning that they do not represent any serious underlying medical condition. 

However, the headache pain itself may be so severe that it often prompts patients to seek urgent and/or emergency evaluation. 

These headaches are almost always severe acute attacks of a chronic migraine headache condition.

Migraine headache is a recurrent, lifelong condition that episodically exacerbates with variable frequency and severity. 

Although common, this condition receives less attention in comparison to other chronic conditions such as diabetes and high blood pressure, so much so that many people don’t even realize that they suffer from migraines. 

This makes managing migraines difficult. 

While frequency and severity of migraines can vary considerably amongst individuals, the following factors can impact migraine flare-ups: 

• Genetics.
  
  
• Life stressors.
  
  
• Lifestyle choices (i.e., diet, exercise, sleep, alcohol use, etc.).
  
  

At Kauai Urgent Care, we do have intramuscular injections (shots) of non-narcotic pain medication(s) that can effectively treat many of these episodes. 

However, there are severe migraine headaches that do require intravenous infusions of powerful narcotic painkillers, which can only be done in the emergency department. 

If you have recurrent migraine headaches, it's important to discuss an acute rescue plan with your primary care physician. It may benefit you to have a small supply of prescription medication on hand at home in order to help treat a migraine attack before it becomes so severe that you need urgent injectable medications. 

It is important to note that there are situations in which a severe headache can be a symptom of an underlying medical condition that requires immediate evaluation by an available medical provider. 

These situations can include: 

• Sudden onset of an extremely severe headache. Sudden onset is defined medically as going from 0 out of 10 to 10 out of 10 on the pain scale in less than 1 minute. This is called thunderclap headache. It is rare but demands immediate emergent medical evaluation, as these patients may often need to get a head CT scan.
• Any new onset severe headache that comes with other obvious new, sudden neurological signs or symptoms – for example, headache with sudden seizure, headache with muscular weakness (especially of one side of the body), headache with sudden vision loss, etc. These situations need evaluation at the emergency department to rule out brain bleeding, stroke or a tumor.
  
  
• (Patients with very poorly controlled, very high blood pressure can rarely bleed acutely into their brain. Acute intracranial hemorrhage is rare, but here on Kauai, poorly controlled, very high blood pressure is very common.

• Any new onset severe headache with a fever more than 100.5 degrees. This could represent a serious infection such as meningitis, which requires immediate ED evaluation as a spinal tap (lumbar puncture) very likely needs to be done. These patients could get admitted directly to the medical center for treatment.
   
• Any new, progressively worsening headache occurring from several hours to a couple days after a recent head trauma. Again, this can represent slow leakage of blood into or around the brain, which might require a CT scan and urgent neurosurgical intervention.
   
• Any new onset severe headache in the later stages of pregnancy, usually during the third trimester. This can present the onset of preeclampsia. This is a special-case scenario that is best evaluated by calling your OB provider directly (or the on-call OB provider) to discuss and determine the need for evaluation.
• All pregnant women should know how to contact their OB provider (or on-call OB provider) after-hours.
   
• Any new onset severe headache in a cancer patient, especially one with advanced-stage cancer, as this can (rarely) represent cancer metastasis to the brain. Again, this is a very unusual and special-case scenario, but there are many cancer patients who are not aware of the possibility of cancer spreading to the brain.
   
• Any new onset severe headache in a substantially immunocompromised patient, such as someone who is un/under treated for HIV, undergoing chemotherapy, is an acute or chronic organ transplant patient, or is taking powerful immunosuppressive drugs to treat a disease.

Published on: December 8, 2017