Subarachnoid Hemorrhage (SAH)
Epidemiology
1:10,000 in USA, 1% of nontraumatic headache
Up to ¼ of sudden severe headaches
Median age = 50 YO
50% 6-mth survival
58% of survivors regain premorbid state
Clinical Features
½ normal neurological exam : V/S, GCS, no neck stiffness
Severe and sudden onset = m/c
Occipitonuchal location
Resolution of pain doesnt exclude Dx
Radiation of pain down along the spine
Diagnosis
Begins with plain CT scan
- (Sensitivity = 93% within 24 hours, more if within12 hours)
- Cannot rule out even within 12 hr
- Sensitivity falls to slightly over 80%
LP is used when
- mandatory following a negative CT
- Low-probability pt : isolated severe headache and absence of neurologic
finding (12%)
- Lone acute sudden headache : acute sudden headache without neck stiffness,
normal neuro exam + V/S + GCS
Gold standard = xanthochromia in CSF supernatant
- 100% sens up to 2 weeks
- 12 hr or longer after headache
- Spectrophotometry
- Naked-eye detection --> 50 % FN
Meningitis
All forms of meningitis can cause headache
LP is required
CT need not if
- normal neurologic examination,
- normal level of consciousness and
- no papilledema
Antibiotics should be started immediately
Intraparenchymal Hemorrhage and Cerebral Ischemia
55 % report headaches at the onset of intraparenchymal hemorrhage
17% in ischemic stroke
6% in TIA
Subdural Hematoma
Hx of remote trauma
Low threshold for initiating Ix is appropriate for high-risk patient
- On anticoagulants
- Chronic alcoholics
- elderly
Brain tumor
Up to 70% complain headache
Classic headache = few
Worse in the morning
Associated with position
N/V
If 24 hr F/U can be ensured, reliable Pt with normal neurologic examination
including papilledema --> OPD
Temporal Arteritis
Epidemiology
Exclusively in Pts over 50 YO
Women
15-30 : 100,000 in this age group
Pathophysiology
Systemic panarteritis that selectively involves arterial walls with significant
amount of elastin
Clinical Features
Headache = m/c symptom (60-90%)
Most often severe, throbbing
Fromtotemporal region
Strong evidence
- Jaw claudication
- Polymyalgia rheumatica
Nonpulsatile or tender artery
Most serious C/P = ischemic optic neuritis
Temporal Arteritis : Dx = 3 in 5
- Age over 50 YO
- New-onset localized headache
- Temporal artery tenderness or decreased pulse
- ESR over 50 mm/hr
Abnormal arterial Bx finding
Treatment
Begin immediately in order to prevent loss of vision
40 60 mg/D prednisolone
Refer urgently for definitive Dx + F/U
Ophthalmic Disorder
Acute glaucoma
- Nausea and vomiting are severe with associated orbital pain.
- Decreased visual acuity and conjunctival injection.
- Patient usually greater than 50 years of age.
Iriditis
Optic neuritis
Hypertension
Higher DBP ass with more severe headache
DDx with
- other secondary headache condition
- Stroke
- Pheochromocytoma
- Preeclampsia
- Secondary to pain and anxiety
Most Pt can be D/C following complete resolution of symptoms and BP reduction
F/U next 24-28 hr
Sinusitis
Maxillary sinusitis commonest type
Headache varies with head position
Symptom predictive of sinusitis
- Colored nasal discharge
- maxillary toothache
- poor response to decongestant
Reliable sign
- Purulent nasal discharge
- abnormal transillumination
>4 --> very likely, <2 --> unlikely
Drug-related and Toxic or Metabolic Headaches
Nitrates, MAOI, chronic use of analgesics
Hypoxia, hypercapnia, hypoglycemia
Monosodium glutamate, CO
Fever greater than 38.8 C is the m/c cause
Benign Intracranial Hypertension (Pseudotumor Cerebri)
Rare entity
Young, obese Pt with long-standing headache
N/V, visual disturbance
Ass with OCP, vit A, tetracycline, thyroid
Character : papilledema, normal LOC and CT, markedly elevated CSF pressure
Acatazolamide or steroid = initial Rx
Repeated LP if fail
Sx : shunt or optic nerve sheath fenestration
Post-Lumbar Punture Headache
10-36 % within 24-28 hr after LP
Persistent CSF leak from dura
Minimized by smaller-bore needle with noncutting tips
Responsive to simple analgesics
If fail --> blood patch
Posttraumatic Headache
Vertiginous sensation, N/V
Markedly improved by recumbency
If unrelieved by lying down --> neuroimaging
Yield is extremely low if cognitive function esp short-term memory is completely
intact
Usu self-limited, NSAIDs may be beneficial
Coital Headache
Before, during, or after orgasm
Severe, persist for several hours
Sentinel subarachnoid hemorrhage must be excluded
Indomethacin 50 mg orally 1-2 hr before intercourse
Summarized By Thirayost Nimmanon
โดย ธีรยสถ์ นิมมานนท์
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