New Onset Persistent HeadacheNew Onset Persistent Headache is one of the five categories of acute headache.These headaches have a known date of onset, and persist. Sometimes the intensity of pain may not be that bad, but the persistent, newness and lack of effective treatment drive the patient to seek advice. Many of these headaches do not have a serious cause. However, some features will be associated with a higher chance of a dangerous headache disorder: These include:
What can you do about about a severe acute headache when tests are normal?More often than not, a new onset persistent headache is investigated and no cause is found.The question is what to do if there is still persistent headache. I would suggest a review of the following 3 areas:
Migraine Rescue and PreventionOur ladder for migraine treatment is as follows:
These are chewed in the mouth and absorbed via the buccal mucosa.or if already had simple analgesic before presentation Make sure there are no contraindications. Allow 2 hours before assessing effectiveness Chlorpromazine has been tested in a randomised trial and is a good choice for persistent headache, as it is widely available and most doctors are familiar with its administration and side effects. This should be administered with the patient lying flat, due to risk of low blood pressure. It can be repeated every 2 hours until a maximum of 37.5mg has been given. It usually causes sedation and induces a deep sleep in people for whom it seems to work well. If you are still stuck, your next options include IV Sodium Valproate 800mg over 1-2 hours, and sometimes IV Methylprednisolone may work, but these are not proven. Anyone who has a migraine successfully treated using this regime should be given oral sumatriptan tablets for future use and given a 3 month course of migraine pevention tablets. They should also be advised on how to lead a Headache Friendly Lifestyle.
Consider Cervicogenic Headache and Epicranial PainsPain from the C2 or C3 nerve roots can cause severe headache. The pain can appear suddenly, but is often unilateral.Occipital Neuralgia is one of the epicranial disorders. There is some controversy as to whether it is s true disorder or whether it is in fact a cervicogenic headache from C2 root entrapment. In either situation (cervicogenic or ooccipital neuralgia) a nerve block with lidocaine (5-10mls of 1% lidocaine is what I usually use) can be worth trying. If there is relief of pain, then a more permanent nerve block with 40mg of methylprednisolone can be administered - but remember that local alopecia can occur in about 2% of cases of steroid injection to the scalp. 
Reconsider the Diagnosis and Think of Other Serious Headache DisordersThe persisting headache with normal CT Brain and Lumbar Puncture could still have a potentially serious cause.It is also worth considering the Indomethacin Responsive Headache Disorders - hemicrania continua and paroxysmal hemicrania. Test doses of 50mg parenteral Indomethacin are used in some centres, although I usually try a week of 25mg three times daily, followed by a week of 50mg three times daily (usually with Lansoprazole cover to prevent NSAID associated gastritis or duodenal ulceration). The specific diagnoses that may occur relatively frequently are: Go Back from Persistent Headache to Acute Headache Severe Headache Expert Home Page |
**Update**
Headache Surveys
- How Severe is Your Headache?
- What Colour is Your Headache?
Results Now Available April 2012 (over 200 responses)
Q. Do people with headaches use colours with negative meaning to describe their headaches?
Q. Do different colours predict different headache diagnoses?
