Protocol on Management of Severe Headache - Swaraj Hospital & Research Institute

Swaraj Hospital & Research Institute

Protocol on Management of Severe Headache

Clinical Guidelines & Emergency Management Pathways

Version: 1.0

Effective Date: June 2026

Location: Bolangir

Department: Emergency & Neurology

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Executive Summary

This protocol provides standardized guidelines for the assessment, investigation, and management of severe headache presentations at Swaraj Hospital & Research Institute. While most acute headaches are primary (benign) in nature, 15-25% of severe presentations indicate serious underlying pathology requiring urgent intervention including subarachnoid hemorrhage, meningitis, acute stroke, or space-occupying lesions.

Protocol Objectives

Rapid identification of red-flag warning symptoms
Appropriate use of diagnostic investigations
Timely specialist referral
Evidence-based pain management
Clear admission and discharge criteria

Introduction & Definitions

Definition of Severe Headache

Severe headache is acute cranial pain of significant intensity (≥7/10 on visual analog scale) affecting the head or upper neck region, requiring urgent assessment to identify life-threatening causes and provide appropriate management.

Clinical Significance

Headache is the 3rd most common ED presentation
85-90% are primary headaches (migraine, tension, cluster)
10-15% have secondary causes requiring intervention
Misdiagnosis of dangerous causes leads to poor outcomes
Early recognition and management reduce morbidity and mortality

Key Principles

High index of suspicion for dangerous causes
Rapid assessment minimizes delays
Appropriate imaging based on red flags
Clear referral pathways established

⚠

Red Flag Symptoms

ANY red flag present requires immediate investigation and likely admission. Do not discharge with reassurance alone.

⚡

Thunderclap Headache

Maximal intensity within 1-2 minutes; suggestive of SAH, dissection, RCVS. STAT imaging required.

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Fever + Neck Stiffness

Classic meningitis triad; requires immediate LP and antibiotics within 60 minutes.

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Focal Neurological Deficit

Weakness, aphasia, ataxia; indicates stroke or mass lesion. Emergency imaging.

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Visual Symptoms

Diplopia, visual field loss, photophobia with vision loss; suggests raised ICP or vascular event.

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Altered Consciousness

Confusion, disorientation, reduced LOC; emergency imaging and monitoring required.

❌

First/Worst Headache of Life

New onset severe, worst ever experienced; always investigate until proven benign.

Additional Risk Factors

Immunocompromised patients
Age >50 (increased risk of GCA, stroke)
History of malignancy
Pregnancy or postpartum period
Anticoagulation therapy
Recent head/neck trauma
Sudden exertional onset

Initial Assessment & Clinical Evaluation

History Taking Components

Onset & Temporal Pattern

Sudden vs gradual onset
Progressive vs stable
Frequency and duration
Time of day when worst

Headache Characteristics

Pain quality: throbbing, pressure, sharp, dull
Severity: 0-10 scale
Location: unilateral, bilateral, focal, diffuse
Radiation pattern

Associated Features

Fever, chills
Nausea, vomiting
Visual symptoms
Weakness, numbness
Confusion, behavioral changes
Neck stiffness

Vital Signs Assessment

Temperature: Fever suggests infection (meningitis, encephalitis)
Blood Pressure: Hypertension may indicate emergency (ICH, eclampsia)
Heart Rate & Rhythm: Tachycardia suggests systemic illness
Respiratory Rate: Altered breathing suggests CNS involvement
Oxygen Saturation: Hypoxia requires intervention

Neurological Examination (Minimum Standards)

Exam Component	What to Assess	Red Flag Finding
Level of Consciousness	Alert vs lethargic vs confused	Altered LOC or confusion
Pupils	Size, symmetry, reactivity to light	Unequal or fixed pupils
Visual Fields	Confrontation testing	Visual field defect
Motor Strength	Arm drift, leg strength (0-5 scale)	Asymmetric weakness
Cerebellar Signs	Gait, balance, coordination	Ataxia or dysmetria
Meningeal Signs	Neck stiffness, Kernig, Brudzinski	Any meningeal sign positive
Fundoscopy	Look for papilloedema	Papilloedema present

Diagnostic Investigations

Imaging Selection

CT Brain (Non-contrast)

First-line Imaging

Indications: All thunderclap headaches, first/worst headache, focal deficits, altered LOC, fever + meningeal signs
Timing: Within 30 minutes
Sensitivity: 95%+ for SAH in first 6 hours
Advantages: Fast, readily available, rules out hemorrhage and mass

CT Angiography (CTA)

Enhanced Vascular Imaging

Indications: SAH suspected, thunderclap with normal CT, arterial dissection suspected
Sensitivity: Excellent for aneurysm and arterial dissection
Timing: STAT if SAH suspected

MRI with MR Venogram

Advanced Imaging

Indications: Subacute/chronic progressive headache, suspected thrombosis, posterior fossa pathology
Advantages: Better tissue resolution, no radiation
Disadvantage: Slower, less accessible acutely

Lumbar Puncture (CSF Analysis)

Meningitis/Encephalitis Diagnosis

Indications: Meningitis strongly suspected, CSF pressure assessment
Timing: Within 60 minutes if bacterial meningitis
IMPORTANT: Perform CT first to rule out contraindications (mass, herniation)
Tests: Cell count, glucose, protein, culture, PCR, Gram stain

Blood Investigations

Test	Indication	What It Detects
CBC	Suspected infection	Elevated WBC suggests infection
ESR/CRP	Age >50 with headache	Inflammation (GCA, vasculitis)
Blood Cultures	Before antibiotics if sepsis	Bacteremia (meningitis)
PT/INR	If anticoagulated	Bleeding risk assessment
Virology PCR	Meningitis suspected	Viral pathogens

Investigation Decision Tree

Assess for Red Flags

Thunderclap, fever + neck stiffness, focal deficit, visual symptoms, altered LOC, first/worst headache?

If RED FLAGS present → STAT CT Brain

Complete within 30 minutes. Notify Neurology and prepare for possible ICU admission.

CT Normal? → Consider next step

If meningitis suspected → LP. If thunderclap → CTA. If improving → Consider discharge.

CT Abnormal → Treat per finding

SAH, ICH, mass, or other pathology identified. Consult appropriate specialist (Neurology, Neurosurgery).

Emergency Management Algorithm

Stabilization (First 10 minutes)

Establish IV access (two lines if severe), Oxygen (SpO₂ ≥94%), Cardiac monitor, NPO status, Quiet dark environment

Rapid Assessment for Red Flags

If red flags present: STAT CT/CTA, Notify Neurology, Request ICU bed. If negative: Proceed to Step 3.

Acute Pain Management

Paracetamol 1g IV/PO OR Ketorolac 30mg IV/IM. Avoid opioids (mask deterioration) and NSAIDs if hemorrhage suspected.

Supportive Care

Anti-emetics if nausea, IV fluids if dehydrated, dark/quiet room for migraine, temperature management if febrile.

Decision & Disposition

If imaging normal and red flags absent + pain controlled → Safe for discharge with return precautions.

Management of Specific Conditions

Suspected Subarachnoid Hemorrhage (SAH)

Immediate Actions:

STAT CT, Neurology + Neurosurgery consult
ICU admission, continuous neuro monitoring
Nimodipine 60mg IV 4-hourly (vasospasm prevention)
Target SBP <160, maintain oxygenation
Avoid hypertension and hypoxia

Suspected Meningitis

STAT Antibiotic Therapy (Do not delay for LP)

Ceftriaxone 2g IV 12-hourly
Vancomycin 15-20mg/kg IV 8-12 hourly
Ampicillin if >50 years or immunocompromised
Dexamethasone 10mg IV with first antibiotic
LP after CT to rule out contraindications
ICU admission

Suspected Acute Stroke

Stroke Protocol:

STAT CT/CTA, Neurology consult
Activate stroke alert
Consider thrombolysis if within therapeutic window
ICU monitoring

Treatment Protocols

Primary Analgesics

Paracetamol (Acetaminophen)

1g IV or PO every 4-6 hours | Maximum 4g in 24 hours

Note: First-line, safe in pregnancy, avoid in severe hepatic disease

Ketorolac (NSAID)

30mg IV/IM single dose, then 10mg PO TID

Contraindications: Renal disease, GI bleed, pregnancy, hemorrhage suspected

Indomethacin

25-50mg PO/rectal TID for 7 days

Best for: Tension headache, cluster headache prophylaxis

Anti-emetics

Prochlorperazine

10mg IV/IM/PO every 6-8 hours

Ondansetron

4-8mg IV/PO every 8 hours

Migraine-Specific Therapy

Sumatriptan (Triptan)

6mg subcutaneous OR 50mg oral (only if migraine confirmed)

Propranolol (Prophylaxis)

40-80mg oral daily-BID (for recurrent migraine >2/month)

Amitriptyline (Prophylaxis)

10-75mg oral at bedtime (for chronic migraine)

Supportive Care Measures

✓ Dark, quiet room (minimizes migraine triggers)
✓ Head elevation 30 degrees
✓ Oxygen if SpO₂ <94%
✓ IV fluids if dehydrated
✓ Temperature control if febrile
✓ Position changes for comfort

Medications to AVOID

Do Not Use If:

Opioids: Mask neurological deterioration, risk of dependence
NSAIDs: Suspected hemorrhage (SAH, ICH, anticoagulated patient)
Excess Analgesics: Risk of medication overuse headache (>10 days/month)

Admission, Discharge & Referral

ADMISSION CRITERIA

Any red flag symptom present
First/worst headache of life
Progressive or unrelenting pain
Fever + meningeal signs
Focal neurological deficit
Altered consciousness
Abnormal imaging findings
Failed outpatient management

SAFE DISCHARGE (ALL required)

Complete neuro exam normal
No red flag symptoms
Imaging normal (if done)
Pain controlled/improving
Reliable patient with support
Clear follow-up arranged
Return precautions explained

NEUROLOGY REFERRAL

Suspected SAH/ICH/stroke
Space-occupying lesion
Recurrent/chronic headache
Migraine requiring prophylaxis
Atypical features
Undiagnosed after workup

Return Precautions for Discharged Patients

Advise Patient to Return Immediately If:

Headache progressively worsens
New weakness, numbness, or difficulty speaking
Vision changes or eye pain
Neck stiffness or fever develops
Confusion or altered consciousness
Seizures occur
Headache different in character from usual

Documentation Requirements

Element	What to Document
Vital Signs	Temperature, BP, HR, RR, SpO₂ with time recorded
Pain Severity	0-10 scale, location, character, onset
Red Flag Assessment	Specific findings or explicitly "no red flags identified"
Neurological Exam	LOC, pupils, motor, cerebellar signs, meningeal signs
Imaging	Type, findings, time completed
Medications	Drug, dose, route, time, response
Final Diagnosis	Primary vs secondary, specific type
Disposition	Admitted to (ward/ICU), discharged, or referred

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References & Guidelines

Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013;87(10):682-687.
Indian Council of Medical Research (ICMR). Standard Treatment Workflow for Management of Headache. Department of Health Research, Ministry of Health and Family Welfare, Government of India. 2024.
South Eastern Sydney Local Health District. Assessment and Management of Headaches in Adults within SESLHD Emergency Departments. SESLHDGL/060. January 2025.
Edvardsson B, Edvinsson L. Principles in evaluation of headache. Neurol Clin. 2019;37(4):745-760.
Orr SL, et al. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department. American Headache Society. 2025.
International Headache Society. International Classification of Headache Disorders (ICHD-3). 3rd ed. 2024.

Disclaimer

This protocol is a clinical guideline based on best practices and available evidence. Individual clinical judgment and patient-specific factors must guide treatment decisions. Any deviations from this protocol should be documented with clinical reasoning.

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Friday, June 26, 2026