Objectives
To appropriately select Pt for emergency Ix and Rx of suspected critical
secondary headache causes
To Dx and effectively treat Pt with generally benign and reversible secondary
headache causes
To provide effective Rx for primary headache syndrome
To provide appropriate dissposition and F/U for all discharged Pt
History
Headache Pattern : Atypical
“First severe headache”
“Worst headache ever”
Began days earlier and steadily worson
Long-standing Hx and significantly different from prior ones in terms of
duration, severity, associated symptoms.
Onset
Sudden-onset and on exertion --> Independent predictor of Intracranial Pathology
--> 25 % = SAH
Location
Non-specific and not reliable for Dx
Migrains – unilateral
TTH – bilateral
Occipito-nuchal location --> Independent predictor of intracranial pathology
(PPV = 16 %) = Most common location for acute SAH
Associated Symptoms
Atypical features : syncope, alteration of consciousness, confusion, neck pain
or stiffness, persistent visual disturbance, fever, seizure
Visual change and eye pain --> glaucoma, iritis
Jaw claudication --> temporal arteritis
Congestion and facial pain --> sinusitis
Other History
Medication : NTG, chronic NSAIDs, MAOI, anticoagulant
Trauma, Toxic exposure (CO)
Prior headache Hx
Results of previous neuroimaging
Comorbid conditions : malignancy, HIV, coagulopation, HTN
Family History
Migraine : migraines or motion sickness
SAH : Relatives with SAH, Risk of ruptured IC aneurysm in first and second
degree relatives is up to 4 times
Physical Examination
Vital Sign
- Fever : infection, SAH
- HTN : hypertensive urgency or emergency
Head and Neck
- Sinus
- Temporal arteries
- Dentition and TMJ tenderness
Eye examination
- Glaucoma or iritis
- Papilledema, absence of venous pulsation
- Subhyaloid hemorrhage (gravity-dependent venous hemorrhage between the
retina and vitreous hemorrhage, convex at ther bottom and flat at the top)
Neurologic Examination : Mandatory
- MSE, CN, motor, sensory
- Papilledema, visual field defects, meningeal signs
- Abnormalities require emergent Ix (PPV for intracranial pathology = 39%)
Ten Headaches to Worry About
Single acute headache, characterized as “first” or “worst” of the patient’s life
Single acute or subacute headache with fever unexplained by other systemic
illness
Single acute or subacute headache with vomiting unexplained by other systemic
illness
Any headache associated with focal findings, unless focality known to be chronic
and unchanged from baseline
Any headache associated with abnormal mental status, unless cognitive changes
are known to be chronic and unchanged from baseline
Any headache associated with loss of spontaneous venous pulsations or
papilledema
Single acute headache with pain on neck flexion, but absent on rotation
Subacute headache, unremitting or progressively worsening
Acute or subacute headache in the elderly
Any headache in the immunocompromised host, esp if HIV-positive or with risk
factor for HIV
Special Consideration
Women vs Migraine
Hormonal factors
Menarche, menstruation, OCP, pregnancy, menopause
Higher estrogen levels ? improved symptoms
Pregnancy
Preeclampsia
Improves migraine symptomes 60-70%
Older Age
Begin over 50 YO ? worrisome and herald the presence of a secondary cause
(one study found that primary headache syndromes still found the commonest Dx)
Children
Most Pts related to underlying febrile illness or trauma
Dental causes
Migraines
- Possible but not frequent
- Rarely does the first headache result in ED
- FHx of Migraine and Motion Sickness
Meningitis, encephalitis, mass, IICP
HTN : If absence of fever --> prompt assessment of BP
Poisonings : CO
Major presentation in shunt malfunction
Chronic : muscle tension, vision disturbance, psychogenic causes
Analgesics and antipyretics is sufficient if thorough examination does not
reveal a life-threatening condition
Using Clinical Data
According to the ACEP groupings
Headache Category
|
Guide to
|
I. Critical
secondary causes requiring emergent identification and treatment
|
-
lEmergent Ix and have Rx initiated
|
II.
Critical secondary causes not necessarily requiring
identification and treatment
|
-
lIx and have Rx initiated as OPD Pt
|
III.
Generally benign and reversible secondary causes
|
|
IV.
Primary headache syndromes
|
|
Investigation of The ED Headache Pt
Computed Tomography Scanning
ED Pt who requires emergent Ix usu begins with non-contrast CT
Noncontrast CT
- usually adequately excludes critical lesions or mass effects requiring
emergent intervention interventions
- Best for Dx acute SAH (but cannot rule out)
Contrast CT
- More time, expense, risk of ADR (10% + 0.1%)
- Needed if strong suspicion of small lesions likely to be missed without
contrast
AIDS suspected of cerebral toxoplasmosis or small brain mass
Lumbar Puncture
Required in cases
- Suspected meningitis
- Suspected SAH with normal CT scan
Contraindications : IICP
- papilledema, AOC, abn neuro exam
- Venous pulsation
- Effectively rule out IICP if present
- May terminated temporally with pressure on the globe
Magnetic Resonance Imaging
More sensitive in brain injuries
DAI, small parenchymal contusion, isodense SDH, most tumors
No more sensitive in acute SAH in first few days
CT + LP are adequate of large majority of ED headache Pt requiring emergent Ix
Summarized By Thirayost Nimmanon
â´Â ¸ÕÃÂÊ¶ì ¹ÔÁÁÒ¹¹·ì
|