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Review
. 2024 Dec;31(12):e16484.
doi: 10.1111/ene.16484. Epub 2024 Sep 17.

"Code Headache": Development of a protocol for optimizing headache management in the emergency room

Javier A Membrilla  1 , Alicia Alpuente  2   3   4 , Laura Gómez-Dabo  2 , García-Yu Raúl  5 , Eduardo Mariño  5 , Javier Díaz-de-Terán  5   6 , Patricia Pozo-Rosich  2   3   4
Affiliations
Review

"Code Headache": Development of a protocol for optimizing headache management in the emergency room

Javier A Membrilla et al. Eur J Neurol. 2024 Dec.

Abstract

Background and purpose: Patients presenting at the emergency room (ER) with headache often encounter a hostile atmosphere and experience delays in diagnosis and treatment. The aim of this study was to design a protocol for the ER with the goal of optimizing the care of patients with urgent headache to facilitate diagnosis and expedite treatment.

Methods: A narrative literature review was conducted via a MEDLINE search in October 2021. The "Code Headache" protocol was then developed considering the available characteristics and resources of the ER at a tertiary care center within the Spanish National Public Health system.

Results: The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify patients based on suspected primary/secondary headaches and the need for pain treatment. Initial assessments, performed by the triage nurse, aim to first exclude potentially high morbidity and mortality etiologies (HEAD1 scale) and then expedite appropriate pain management (HEAD2 scale) based on scoring criteria. HEAD1 evaluates vital signs and symptoms of secondary serious headache disorders that can most benefit from earlier identification and treatment, while HEAD2 assesses symptoms indicative of status migrainosus, pain intensity, and vital signs. Subsequently, ER physicians employ a third assessment that reviews red flags for secondary headaches (grouped under the acronym 'PEACE') to guide the selection of complementary tests and aid diagnosis.

Conclusions: The Code Headache protocol is a much needed tool to facilitate quick clinical assessment and improve patient care in the ER. Further validation through comparison with standard clinical practice is warranted.

Keywords: emergency department; emergency room; headache; migraine; red flags; secondary headache; status migrainosus.

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Conflict of interest statement

Membrilla JA has received honoraria for teaching activities from TEVA, Lilly and Novartis and for advisory from Pfizer. Alpuente A has received honoraria as a speaker from Lundbeck, Allergan‐Abbvie, Novartis, Lilly, TEVA and as a consultant from Medlink. Gomez Dabo L does not have any conflicts of interest. García‐Yu R and Mariño E report no conflict of interest. Diaz‐de‐Terán J has received honoraria for advisory boards from speaker panels from Novartis, Lilly, TEVA, Abbvie‐Allergan, Lundbeck Pfizer and Boston Scientific. In the last three years, Pozo‐Rosich P has received honoraria as a consultant and speaker for: Abbvie, Eli Lilly, Lundbeck, Medscape, Novartis, Pfizer and Teva. Her research group has received research grants from AbbVie, Novartis and Teva, as well as Instituto Salud Carlos III, EraNet Neuron and European Regional Development Fund (001‐P‐001682) under the framework of the FEDER Operative Programme for Catalunya 2014‐2020–RIS3CAT; has received funding for clinical trials from AbbVie, Amgen, Biohaven, Eli Lilly, Lundbeck, Novartis, Pfizer and Teva. She is the Honorary Secretary of the International Headache Society. She is in the editorial board of Neurologia, and Revista de Neurologia, associate editor for Cephalalgia, Headache and The Journal of Headache and Pain. She is a member of the Clinical Trials Guidelines Committee and Scientific Committee of the International Headache Society. She has edited the Guidelines for the Diagnosis and Treatment of Headache of the Spanish Neurological Society. She is the founder of www.midolordecabeza.org. Pozo‐Rosich P does not own stocks from any pharmaceutical company.

Figures

FIGURE 1
FIGURE 1
The Code Headache protocol algorithm. BP, blood pressure; CT, computed tomography; ER, emergency room; VAS, visual analogue scale.
See this image and copyright information in PMC

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