Announcements: Neuromuscular section updated with more questions.


  • New headache or personal history of headaches, and is this one different?
  • Location ? Quality ? Severity ?
  • Onset (sudden or gradual)?
  • Preceding aura?
  • Transient visual obscuration, especially with valsalva?
  • Associated features (nausea / vomiting / photophobia / phonophobia / diplopia / tinnitis)?
  • What and how much have they taken for the headaches?
  • Worsening factors (e.g. laying down, standing up, straining)?
  • Diurnal pattern (e.g. worse in the morning)?
  • OCP or Vitamin A / retinoid use? Recent weight gain?
  • Any patient recently postpartum or with systemic cancer, HIV, or taking immunosuppressive drugs should be assumed to have a secondary headache until proven otherwise

If chronic headache syndrome, ask about family history of headaches and screen for lifestyle factors: caffeine use, sleep, hydration status, frequency of analgesic use, relation to menses, stress, relation to weather

If new headache syndrome, screen for red flags: recent head or neck trauma, chiropractor visits, fevers or chills, recent travel or sick contacts, altered mental state, neck stiffness, focal neurologic or visual deficits

If associated visual changes in an older person, screen for GCA: fever, weight loss, jaw claudication, scalp tenderness, proximal limb myalgias, constitutional symptoms


  • vitals including temp and blood pressure
  • full neurologic exam including Fundoscopic and visual fields, nuchal rigidity, focal neurologic deficits including Horner’s syndrome, scalp tenderness

WORKUP:  ESR necessary if patient is older (corrected ESR = (age + 10 if female)/2)

PLAN: should be dictated by patient’s history and physical

If no red flags, can start treatment with:

  • IV hydration
  • Reglan 10 mg IV (can repeat q6h, benadryl/ativan to reverse akathisia)
  • Toradol 30 mg IV (can repeat q6h, caution for renal disease)
  • Magnesium sulfate 2 g IV
  • Refractory: Depakote 1000 mg IV x 1, Solu-medrol 1 g IV x 1

If red flags present: further workup including LP, neuro-imaging, and ophtho consult may be warranted

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