1
Q
What are the care objectives of AV CPG A0502 Headache?
A
Risk stratify patients with headache and select the appropriate care pathway based on their risk profile.
2
Q
What are the two care pathways for headache management in AV CPG A0502?
A
High-risk patients are transported to ED and low-to-moderate risk patients may be referred to VVED.
3
Q
What patient age group does AV CPG A0502 apply to?
A
Patients aged 16 years or older.
4
Q
What are the two broad categories of headache?
A
Primary headaches and secondary headaches.
5
Q
What defines a primary headache?
A
A neurological headache disorder not due to another underlying condition.
6
Q
Give examples of primary headaches.
A
Migraine, tension headache, and cluster headache.
7
Q
Are primary headaches life-threatening?
A
No, they are painful but generally benign.
8
Q
What defines a secondary headache?
A
A headache caused by an underlying pathology.
9
Q
Give examples of serious causes of secondary headache.
A
Intracranial haemorrhage and meningitis.
10
Q
Give examples of benign causes of secondary headache.
A
Influenza or dehydration.
11
Q
Why is distinguishing between primary and secondary headaches important?
A
It determines the appropriate care pathway and urgency of investigation.
12
Q
What is the primary focus of paramedic headache management?
A
Identifying high-risk features suggesting serious secondary headache.
13
Q
What is the estimated prevalence of migraine in Australia?
A
Approximately 4.9 million people or about 20.55% of the population.
14
Q
Why might many headache patients present to ambulance?
A
A primary headache not responding to usual treatment or a benign secondary headache without high-risk features.
15
Q
When may referral to VVED be appropriate for headache patients?
A
When the headache is low-to-moderate risk without high-risk features.
16
Q
What additional capabilities can VVED provide for headache patients?
A
Diagnostic support, prescribing medications, authorising additional therapies, monitoring response to treatment, and providing safety-netting.
17
Q
What medication therapy outside paramedic scope may VVED authorise?
A
High-dose aspirin.
18
Q
Why might VVED monitoring be useful in headache management?
A
It allows assessment of response to treatment and identification of diagnostic error.
19
Q
What components should be assessed when evaluating a headache?
A
Associated symptoms, character, comorbidities, duration, frequency, location, medications, onset, precipitating factors, severity, and usual care plan.
20
Q
Why should a patient’s usual headache care plan be considered?
A
It may guide treatment and should be followed if not already implemented by the patient.
21
Q
What associated symptoms should be asked about when assessing headache?
A
Aura, nausea, vomiting, photophobia, autonomic symptoms, neck pain, and fever.
22
Q
What does the presence of aura before a headache suggest?
A
Migraine.
23
Q
Why is fever with neck pain concerning in headache assessment?
A
It is a red flag suggesting meningitis.
24
Q
Why is the character of headache pain important?
A
Changes in quality, frequency, or intensity may indicate a serious cause.
25
What comorbidities should be considered in headache assessment?
Anxiety, depression, hypertension, pregnancy, previous stroke, and immunosuppression.
26
Why is duration of headache episodes relevant?
It helps distinguish between headache types and acute versus chronic patterns.
27
What duration is unlikely to represent tension headache or migraine?
Headaches lasting only seconds.
28
What is the importance of assessing headache frequency?
It helps distinguish acute headache from chronic headache disorders.
29
What location features should be assessed in headache?
Whether the pain is unilateral or bilateral and whether it radiates.
30
What headache types are commonly unilateral?
Migraine and cluster headaches.
31
Why should medication history be taken in headache assessment?
Medication overuse can cause headache and knowledge of prior therapy guides management.
32
What onset characteristics raise concern in headache?
Sudden onset or onset after age 50.
33
Why is sudden onset headache concerning?
It may indicate subarachnoid haemorrhage or other vascular causes.
34
What precipitating factors should be asked about in headache history?
Triggers such as standing, lying flat, coughing, sneezing, or exertion.
35
Why is headache worsened by coughing or sneezing concerning?
It may indicate raised intracranial pressure.
36
What does headache severity assessment help determine?
The degree of functional disability caused by the headache.
37
At what age does migraine commonly begin?
Typically adolescence but it may occur at any age.
38
How long do migraine episodes usually last?
Between 4 and 72 hours.
39
What may precede migraine headache?
An aura lasting approximately 5–60 minutes.
40
What types of aura can occur before migraine?
Visual, sensory, speech, or motor disturbances.
41
Describe the typical migraine headache.
Unilateral pulsating or throbbing pain of moderate to severe intensity worsened by physical activity.
42
What gastrointestinal symptoms commonly occur with migraine?
Nausea and vomiting.
43
What sensory sensitivities commonly occur with migraine?
Photophobia and sensitivity to noise.
44
What environmental preference do migraine sufferers often have?
Prefer lying still in a dark quiet room.
45
What neurological symptoms may occur during migraine?
Various neurological disturbances may occur.
46
Why should paramedics avoid diagnosing migraine without previous history?
Migraine symptoms can mimic stroke, intracranial haemorrhage, or meningitis.
47
Does a normal GCS rule out intracranial haemorrhage or SAH?
No.
48
What is the purpose of high-risk headache criteria?
To rapidly identify secondary headaches associated with high morbidity or mortality.
49
What clinical decision tool informs many headache red flags?
SNNOOP10.
50
What does the SNNOOP10 concept relate to?
Red flag features suggesting serious secondary headache.
51
What systemic sign is a red flag for secondary headache?
Fever.
52
What past medical history raises concern for secondary headache?
History of neoplasm.
53
What neurological features are red flags in headache?
Neurological deficits or altered consciousness.
54
What onset characteristic strongly suggests subarachnoid haemorrhage?
Sudden or abrupt onset headache.
55
Why is new headache after age 50 concerning?
It may indicate vascular disorders, neoplasm, or giant cell arteritis.
56
What pattern change in headache may indicate serious pathology?
Recent onset or change in headache pattern.
57
What does positional headache suggest?
Intracranial hypertension or hypotension.
58
What may headache triggered by coughing, sneezing or exercise indicate?
Posterior fossa malformations or raised intracranial pressure.
59
What ocular sign is a red flag in headache?
Papilloedema.
60
Why is progressive headache concerning?
It may indicate intracranial pathology such as neoplasm.
61
Why is pregnancy or puerperium a red flag for headache?
Risk of conditions such as cerebral sinus thrombosis or preeclampsia.
62
What eye symptom with autonomic features suggests pathology?
Painful eye with autonomic features.
63
Why is post-traumatic headache concerning?
It may indicate intracranial injury such as subdural haematoma.
64
Why is immunosuppression a red flag for headache?
It increases risk of opportunistic infections.
65
How can medication use cause headaches?
Painkiller overuse or new drug reactions may trigger headache.
66
Why are headaches after significant head trauma concerning?
They are strong predictors of intracranial pathology.
67
Why should elderly patients with headache after minor trauma be transported more readily?
They are more susceptible to serious injury such as chronic subdural haematoma.
68
What factors should be considered when evaluating post-traumatic headache?
Mechanism of injury, time to symptom onset, age, and baseline fitness.
69
Why are opioids generally avoided in headache management?
They have limited benefit and may delay recovery or reduce effectiveness of other treatments.
70
When may fentanyl be used for headache?
When pain is severe, other treatments have failed, and transport time exceeds 15 minutes.
71
What medication may benefit migraine especially with nausea or vertigo?
Prochlorperazine.
72
What is the prochlorperazine dose for migraine in this CPG?
12.5 mg IM.
73
What is the minimum age for prochlorperazine administration for migraine?
21 years.
74
Why should prochlorperazine not be given in suspected ICH or SAH?
It increases risk of adverse effects such as hypotension and oversedation.
75
What adverse effects may occur with prochlorperazine?
Oversedation, hypotension, extrapyramidal effects, and seizures.
76
When should paramedics administer aspirin for headache?
Only on advice from VVED or as part of a patient’s management plan.
77
What dose of aspirin is typically used for migraine treatment?
900–1000 mg.
78
What supportive treatments may assist severe headache management?
Management of nausea, vomiting, and dehydration.
79
What vital investigations should be performed in headache assessment?
Vital signs and blood glucose.
80
What analgesic should all headache patients receive unless contraindicated?
Paracetamol.
81
What is the standard paracetamol dose for headache?
1000 mg orally.
82
What reduced paracetamol dose should be used in frail or elderly patients?
500 mg orally.
83
When may prochlorperazine be used in headache management?
In patients suspected or diagnosed with migraine.
84
What oxygen therapy is recommended for cluster headache?
10–15 L/min oxygen via non-rebreather mask.
85
What is the disposition for low-to-moderate risk headache patients?
Paramedic initiated VVED referral.
86
What symptom defines thunderclap headache?
Sudden onset severe headache reaching peak intensity rapidly.
87
What symptom is described as “worst headache of life”?
A classic presentation of possible subarachnoid haemorrhage.
88
Name neurological features that indicate high-risk headache.
Acute neurological deficit or altered mental state.
89
What trauma history raises concern for secondary headache?
Recent significant head trauma.
90
What past medical history increases risk for secondary headache?
Previous intracranial haemorrhage or known aneurysm.
91
Why is seizure without epilepsy concerning in headache?
It may indicate intracranial pathology.
92
What features suggest meningitis or encephalitis?
Fever, neck stiffness, and photophobia.
93
What rash is concerning in headache with infection?
Non-blanching rash.
94
What immune conditions increase infection risk causing headache?
HIV infection or chemotherapy.
95
What history suggests raised intracranial pressure causes?
Prior neurosurgery or VP shunt.
96
What cancer history raises concern for secondary headache?
History of neoplasm.
97
What headache feature requires further investigation even if otherwise stable?
Headache different to usual pattern.
98
What toxic exposures may cause secondary headache?
Poisoning or envenomation.
99
What drugs are associated with secondary headache risk?
Amphetamines and cocaine.
100
Why is pregnancy or postpartum headache concerning?
Risk of preeclampsia or cerebral vascular complications.
101
What age-related red flag exists for headache?
New severe headache in patients over 50.
102
Why are anticoagulated patients with new headache high risk?
Increased risk of intracranial bleeding.
103
What is the disposition for high-risk headache patients?
Transport to emergency department.
104
What analgesia should high-risk headache patients receive?
Paracetamol as per Pain Relief CPG.
105
When should fentanyl be considered for severe headache?
If pain remains severe 15 minutes after paracetamol and transport time exceeds 15 minutes.
106
What pain score target should be aimed for in severe headache management?
Reduction of pain to less than 7 out of 10.
107
Which additional CPGs may apply to severe headache presentations?
Suspected Stroke or TIA, Meningococcal Septicaemia, Pre-eclampsia/Eclampsia, and Nausea and Vomiting.
108
When is prochlorperazine contraindicated in headache management?
In patients with CNS depression.
109
What symptoms should be asked about when assessing associated symptoms in headache history?
Aura, nausea, vomiting, photophobia, autonomic symptoms, neck pain, and fever.
110
What example question can be used to assess associated symptoms in a headache history?
“Do you experience any other symptoms such as aura, nausea, vomiting, photophobia, autonomic symptoms, neck pain, or fever?”
111
What does aura preceding headache suggest?
Migraine.
112
What combination of symptoms is considered a red flag for secondary headache when assessing associated symptoms?
Fever associated with neck pain.
113
What example questions assess the character of a headache?
“What does the headache feel like (e.g. pulsatile, throbbing, pressure-like)?” and “Has the headache changed in intensity or frequency?”
114
Why is assessing headache character important?
Changes in quality, frequency, or intensity require further evaluation.
115
What example question assesses comorbidities in headache history?
“Are there other medical problems that might be related to the headache?”
116
What comorbidities should be specifically asked about during headache assessment?
Anxiety, depression, hypertension, pregnancy, previous stroke, and immunosuppression.
117
Why are comorbidities important when assessing headache?
They must be factored into the final diagnosis and management plan.
118
What example question assesses duration of headache attacks?
“How long does each attack last (seconds, minutes, hours, or days)?”
119
What duration of headache is unlikely to represent migraine or tension headache?
Headaches lasting only seconds.
120
What example question assesses frequency of headaches?
“How often do the attacks occur (e.g. days per month)?”
121
What additional question should be asked when assessing headache frequency?
“How many days per month are you headache-free?”
122
Why is assessing headache frequency useful?
It helps distinguish between acute and chronic headache.
123
What example questions assess the location of headache pain?
“Where is the pain?”, “Is the headache unilateral or bilateral?”, and “Does it radiate, and if so where?”
124
What headache types commonly present with unilateral pain?
Migraine and cluster headache.
125
What example question assesses medication history for headache?
“What medications have you taken for the headache?”
126
Why is medication history important in headache assessment?
Medication overuse can lead to headache and knowledge of the usual care plan helps inform new therapies.
127
What example questions assess onset of headache?
“At what age did the headaches begin?” and “Was the onset sudden or gradual?”
128
What onset characteristics raise concern for serious headache?
Sudden onset and onset at age 50 years or older.
129
What example questions assess precipitating or provoking factors for headache?
“Are there symptoms before the headache starts such as aura or jaw pain?” and “Does anything make the headache worse such as standing up, lying flat, sleep, coughing, or sneezing?”
130
Why are precipitating factors important when assessing headache?
Migraines may have predictable triggers, while headaches worsened by positional change or coughing/sneezing are more concerning.
131
What example questions assess headache severity?
“How bad is the pain on a scale of 1 to 10?” and “How does the headache affect your daily functioning?”
132
Why is severity assessment important in headache evaluation?
It helps determine the degree of disability caused by the headache.
133
What systemic sign is a red flag for secondary headache?
Fever.
134
What conditions may cause headache associated with systemic signs such as fever?
Infection, nonvascular intracranial disorders, carcinoid syndrome, or pheochromocytoma.
135
Why is a history of neoplasm concerning in a headache patient?
It may indicate brain neoplasms or metastases.
136
What neurological sign is considered a red flag in headache evaluation?
Neurological deficit including altered conscious state.
137
What conditions may cause headache associated with neurological deficit?
Vascular intracranial disorders, nonvascular intracranial disorders, brain abscess, or infections.
138
What headache characteristic strongly suggests subarachnoid haemorrhage?
Sudden or abrupt onset headache.
139
What conditions are associated with sudden onset headache?
Subarachnoid haemorrhage and other cranial or cervical vascular disorders.
140
Why is new headache after age 50 concerning?
It may indicate giant cell arteritis, vascular disorders, neoplasms, or other intracranial disorders.
141
What conditions are associated with headache beginning after age 50?
Giant cell arteritis, cranial or cervical vascular disorders, neoplasms, and other intracranial disorders.
142
What does a pattern change or recent onset of headache suggest?
Neoplasms or intracranial vascular and nonvascular disorders.
143
What condition may cause positional headache?
Intracranial hypertension or intracranial hypotension.
144
What pathology may cause headache precipitated by sneezing, coughing, or exercise?
Posterior fossa malformations or Chiari malformation.
145
What condition is associated with papilloedema in headache patients?
Neoplasms, intracranial hypertension, or other nonvascular intracranial disorders.
146
What conditions may cause progressive headache or atypical headache presentations?
Neoplasms or other nonvascular intracranial disorders.
147
Why is pregnancy or puerperium considered a red flag in headache assessment?
It may indicate conditions such as cerebral sinus thrombosis, preeclampsia, or vascular disorders.
148
What conditions may cause headache in pregnancy or puerperium?
Cranial or cervical vascular disorders, post-dural puncture headache, hypertension-related disorders such as preeclampsia, cerebral sinus thrombosis, hypothyroidism, anaemia, or diabetes.
149
What conditions may cause painful eye with autonomic features in headache patients?
Pathology in the posterior fossa, pituitary region, cavernous sinus, Tolosa-Hunt syndrome, or ophthalmic causes.
150
What conditions are associated with post-traumatic headache?
Acute or chronic post-traumatic headache, subdural haematoma, and other trauma-related headache disorders.
151
Why is pathology of the immune system a red flag for headache?
It increases the risk of opportunistic infections.
152
What type of infections are associated with headache in immunocompromised patients?
Opportunistic infections.
153
What headache condition may result from painkiller overuse?
Medication overuse headache.
154
What may cause headache related to new medication use?
Drug incompatibility.
Pain Relief
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