(Featured Image, Wikimedia Commons, JD Fletcher)
I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here.
As summarised from Rosen’s 8th p1389 and the UK NICE Guideline on headache
- Only headache commoner in men than women
- classically late 20s smoker
- alcohol thought to be a precipitant of a cluster
- episodes from 15mins to several hours with rapid resolution
- pain confined to trigeminal distribution
- often features of agitation, pacing and rubbing the head
- ispilateral autonomic features are a key
- ptosis or miosis (remember these are mediated by sympathetic and parasympathetic systems and not necessarily a more concerning specific cranial nerve problem (typically a 3rd or a Horner’s syndrome)
- facial sweating
- eye is often red and watering
Recommended UK management?
- high flow O2 is the famous one (NNT of 2 apparently)(NICE)
- other migraine therapies seem useful
- sumatriptan nasal or sub cut but NOT oral (NICE)
- your dopamine agonist of choice
- headaches will likely recur and like migraine steroids have been proposed as has verapamil to prevent recurrence (NICE states use verapamil)
- The American Headache Society as a management guide for health professionals that largely reinforces everything above with no mention of our beloved dopamine agonists but they do add in topical nasal lignocaine drops as an option