Josh McFadden

Josh McFadden


By Josh McFadden

Having a headache is hardly an uncommon occurrence. In fact, the World Health Organization (WHO) states that “nearly everyone has a headache occasionally.” Headaches can vary in severity and duration from a slight annoyance that lasts a matter of minutes, to a life-altering, debilitating condition that is virtually constant.

Sometimes a headache is hardly noticeable, not affecting one’s daily routine or ability to accomplish tasks or enjoy activities. Other times, however, a headache can render children and adults alike incapable of functioning at a normal level.

One type of headache is a migraine, a neurological disease that is much more than simply a bad headache.

Migraines are characterized by an intense, recurring throbbing on the side of the head; about one-third of migraine episodes are accompanied by pains on both sides of the head. Migraines also cause other symptoms such as nausea, vomiting, dizziness, visual disturbances, and tingling or numbness in the face, fingers, or toes. Those suffering from migraines also can be overly sensitive to sound, light, touch, and smell.1

Migraine sufferers can experience more than just physical pain. It is not rare for people with this disease to have bouts of depression, anxiety, or trouble sleeping.2

The statistics

It may be surprising to some just how prevalent migraines are. If you regularly combat migraines, you are hardly alone.

In the United States, about 38 million people suffer from migraines. This amounts to more than 12 percent of the population. One in seven people on Earth experience migraines. Interestingly, migraines affect three times as many women in the U.S. than they do women in other countries (18 percent vs. 6 percent). And the chances are pretty good that plenty of people around you deal with this troubling disease: One in four U.S. households have someone that suffers from migraines.3

Migraines seem to affect young adults and the middle-aged more than any other age groups, as the disease is most common among those aged 25–55. The disease appears to have a connection to heredity as well. One parent with migraines has a 40 percent chance of passing on this condition to his or her children. Alarmingly, if both parents experience migraines, they have a 90 percent chance of their children suffering the same fate.4

Migraines know no bounds. These painful episodes can come to children, adults, and the elderly. In fact, migraines are more common among Americans than diabetes and asthma combined.

Migraine attacks can last anywhere from four hours to three days. For some people, living with migraine pain and discomfort is a daily struggle, as 14 million people in the U.S. have migraines every day.5

The causes

Unfortunately, scientists and medical professionals are not exactly sure what triggers migraines. One widely accepted explanation is known as the neurovascular theory. This states that “various triggers cause abnormal brain activity, which in turn causes changes in the blood vessels in the brain.”6

The Mayo Clinic has stated that migraines might be brought upon by certain things such as cheeses, salty foods, and processed foods. It’s possible that skipping meals could also be a factor in the incidences of migraines. The Mayo Clinic further reports that food additives (namely, the sweetener aspartame), alcoholic beverages, highly caffeinated drinks, stress, intense physical activity, weather changes, and use of contraceptives may contribute to migraine activity.7

Additionally, the Mayo Clinic states that migraines may be caused by changes in the brain stem or imbalances in brain chemicals, such as serotonin.

Addressed in the Medical Protocol

In the Medical Priority Dispatch System (MPDS®) v13.0, migraines are handled on Protocol 18: Headache and are listed under the “Not Serious Types and Causes” category along with cluster, sinus, and tension headaches.

Though one might not consider a migraine to be a condition meriting emergency care, consider that every 10 seconds a person in the United States goes to the emergency room with a headache or migraine.8 In fact, as Axiom 4 points out, “Patients who call an ambulance for a headache generally have a more serious underlying cause than patients who arrive at the emergency department on their own.”

It is due to the possibility of a severe underlying cause that several new v13.0 components were added to Protocol 18. These enhancements specifically guide the EMD on how to address a possible stroke identified on this protocol, including a new Key Question, a prompt to use the Stroke Diagnostic Tool, new Rules and Axioms, and a new CEI (Critical EMD Information) that prompts the EMD to provide hospital staff with the Stroke Diagnostic Tool results, symptom onset time, and the contact information of anyone who witnessed the symptom onset.

Protocol 18 contains seven direct and simple Key Questions designed to first determine the patient’s level of alertness and breathing (KQ 1 and 2) and then identify any other symptoms that may indicate a serious underlying cause of headache. For this reason, Key Questions 3–6 are critical to determine whether the patient has shown any symptoms of a stroke.

For instance, Key Question 4 on Protocol 18 asks, “Was there a sudden onset of severe pain?” This question is crucial because, as Rule 1 states, “Sudden onset of a severe headache is considered to have a more serious underlying cause until proven otherwise.” Furthermore, Axiom 2 states, “Headaches that are both sudden and severe, especially when associated with movement problems (numbness or paralysis), may represent the early onset of a serious condition.”

Five “Serious Types and Causes” of headaches are identified on Protocol 18 as berry aneurysm rupture, epidural hematoma, intracerebral hemorrhage, ischemic infarction, subarachnoid hemorrhage, and subdural hematoma. In addition, hypertension, meningitis, and post-traumatic (hit head) are listed as “Possibly Serious Types and Causes.”

It is not the EMD’s responsibility to diagnose the patient’s problem but rather to follow the protocol step by step, asking each question as it is written. The associated lists of varying types and causes simply serve as a reference for the EMD.

In short, as stated in Axiom 1, “The most important objective of this protocol is to determine if the underlying cause of a headache might be a life-threatening but potentially treatable condition such as STROKE, meningitis, or other serious brain condition. Headache, in and of itself, is not a diagnosis but a very general symptom of many other low-acuity problems.”

If the EMD identifies a stroke symptom in Key Questioning, he or she then asks the new Key Question 7, “Exactly what time did these symptoms (problems) start?” If unknown, the EMD will ask about the time frame of when the patient was last seen to be normal. As explained in the Additional Information, the time of symptom onset is vital to the hospital and responders as an important part in preparing the patient’s therapy.

After inquiring about the initial onset, the EMD will then use the Stroke Diagnostic Tool to assess whether there is CLEAR, STRONG, PARTIAL, or No test evidence of stroke. The EMD then adds the diagnostic results in the form of a suffix attached to the Determinant Code, which is factored into the correct response.

Initiating a response

Although stroke is a time-sensitive event, it is classified as a CHARLIE-level response. Rule 2 explains “STROKE must receive an immediate response that is not subject to delay. Lights-and-siren are not recommended; however, there should be a sense of urgency.” For this reason, EMDs should assign a CHARLIE-level Determinant Code to callers with any of the following complaints:

  • not alert (18-C-1)
  • abnormal breathing (18-C-2)
  • speech problems (18-C-3)
  • sudden onset of severe pain (18-C-4)
  • numbness (18-C-5)
  • paralysis (18-C-6)
  • change in behavior in the past three hours or less (18-C-7)
If the patient’s status is unknown or other codes are not applicable, the EMD should initiate an 18-B-1 response. If the caller reports that the person suffering headache symptoms is breathing normally (Key Question 2) and does not have any of the symptoms identified in the other Key Questions, the EMD should initiate an 18-A-1 response.


1 “Migraine Fact Sheet.” Migraine Research Foundation. 2015. (accessed Aug. 19, 2015).

2 See note 1.

3 See note 1.

4 See note 1.

5 See note 1.

6 “Migraines and Headaches Health Center.” WebMD. 2015. (accessed Aug. 19, 2015).

7 “Diseases and Conditions: Migraines.” Mayo Clinic. 2015. (accessed Aug. 19, 2015).

8 See note 1.

9 Clawson JJ, Dernocoeur KB, Murray C. Principles of Emergency Medical Dispatch. Fifth Edition. International Academies of Emergency Dispatch; Salt Lake City. 2014.