The management the secondary headaches listed below is outlined here:


The most important treatment is that of the underlying cause.

Heparin should be commenced to reduce the risk of clot extension. However, this can increase the risk of cerebral haemorrhage.

In patients with a deteriorating conscious level, a neuro-radiologically guided catheter delivering thrombolytic therapy should be considered.

Phenytoin should be commenced in patients presenting with seizures.

Brain tumours

Only stroke causes more neurological mortality than brain tumours.

80% of primary brain tumours are high-grade gliomas (glioblastoma multiforme). The median survival time from the time of diagnosis without any treatment is 3 months; even with optimal treatment less than 25% survive 2 years. Death occurs due to cerebral oedema or raised intra-cranial pressure.

Brain metastases occur in up to 30% of cancer patients. Mean survival is less than 12 months.

For both primary and secondary lesions, treatment in the ED is usually limited to steroid therapy to reduce oedema and relieve ‘mass effect’ symptoms.

Steroids are particularly useful where there is extensive vasogenic oedema, as occurs in high grade gliomas and metastases.

Learning Bite

The optimal dose of dexamethasone in the treatment of brain tumours (primary and secondary) is 4 mg/day. This has been shown to improve symptoms and function as effectively as larger doses whilst minimising side effects.

Idiopathic intracranial hypertension

The diagnosis can only be made by measuring the CSF pressure.

Withdrawing 5-10 ml of cerebrospinal fluid will usually relieve the pressure and ease the headache.

The ultimate goal is to reduce the CSF pressure to <200mmHg, or until symptoms resolve.

If there is evidence of visual damage, the management needs to be more aggressive and includes:

  • Urgent referral to ophthalmology
  • Treatment with furosemide and acetazolamide to reduce CSF production
  • Possible surgery

Temporal arteritis

Steroids should be commenced in anyone in whom the diagnosis is suspected.
Prednisolone 1mg/kg per day is the starting dose.
Steroids do not interfere with the biopsy findings of the temporal artery if the biopsy is undertaken within one week of commencing medication.

Carbon monoxide poisoning

All patients suspected of CO poisoning should receive 100% O2 therapy via a close-fitting mask. Those with a diminished level of consciousness may benefit from hyperbaric O2 therapy.

Further discussion of this subject can be found in the following session about carbon monoxide poisoning.

Further information on other conditions can be found in the following sessions:

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