Inpatient Headache

Inpatient Headache (HA)


  • Important to distinguish 1º° and 2º° headache
  • Red flags for 2º° headaches (SNOOP): Systemic symptoms, Neurologic symptoms, Onset that is sudden (thunderclap), Older age (new headache >40), Progression or evolution in previous headaches [the ‘P’ is also used for Positional component]
    • Other red flags: preceding trauma, HA awakening pt from sleep, no HA-free intervals
    • Thunderclap suggests that maximal HA intensity develops within 10 seconds



  • Get a good description of where the pain is, when, associated symptoms, and assess for “red flag” features listed above
  • If there are any red flag features imaging and workup are necessary
  • Imaging depends on highest suspicions, but CTA head/neck is appropriate to evaluate for aneurysm (including neck to consider dissection). If any focal signs, MRI is generally preferred; venous imaging can be beneficial in headaches with features of elevated ICP
  • If no red flag features, then workup is not necessary, and focus is on treatment  



  • NSAIDs and Tylenol for infrequent headaches, but consistent use (>2-3 a week) runs the risk of rebound headaches
  • Triptans for migraine, but contraindicated in patients with CAD, uncontrolled HTN, previous stroke
    • There are theoretical concerns of serotonin syndrome when used with SSRI/SNRIs
  • Acute migraine in hospital: “migraine cocktail” -> 1 L fluid bolus, 2-4 grams of magnesium sulfate, IV Compazine (10mg)/Phenergan(20mg)/Reglan (20mg) with Benadryl (25mg)
    • If that does not work: Depakote 1000 mg IV, decadron 10mg IV , +/- toradol 30mg IV, flexeril 10mg PO
  • Cluster headache – also responds to triptans, high flow O2 (>10 L), sometimes intranasal lidocaine if no arrhythmia history